HIPs

Most women around the world begin sexual relationships between the ages of 15 and 19 and face significant challenges in obtaining services and information to protect themselves from unwanted pregnancy and sexually transmitted infections, including HIV (Bankole and Singh, 2003; UNFPA, 2014; Wellings et al., 2006). As the world’s population of 15- to 19-year-olds continues to grow beyond 600 million, countries will need to meet increasing demand for contraceptive services and information that address their specific needs (UNDP, 2015).

Historically, programs have supported either stand-alone adolescent clinics that offer contraceptive services, or adolescent-friendly contraceptive services offered in a separate room or in an “adolescent corner” within an existing health facility (Senderowitz, 1999). These programs demonstrate mixed effects (Denno et al., 2015; Tylee et al., 2007). Additionally, scale-up has been challenging for many countries due to complexity of the programs, and resource requirements threaten their longterm sustainability (Hainsworth et al., 2014).

To inform the next generation of programs, experts in adolescent sexual and reproductive health were asked to propose a streamlined approach, based on learning to date, that would be both scalable and sustainable. Mainstreamed AdolescentFriendly Contraceptive Services (AFCS) incorporate within existing contraceptive services those adolescent-friendly elements that have demonstrated effectiveness in stand-alone or separate-space models. These elements can be incorporated into a range of service delivery channels (i.e., facilities, mobile outreach, community-based distribution, pharmacies, or drug shops). Drawing from a variety of literature reviews, a number of common program elements were identified that can increase contraceptive use among adolescents (Bankole and Malarcher, 2010; Senderowitz, 1999).

Common service delivery elements include:

• Training and supporting providers to offer nonjudgmental services to adolescents
• Enforcing confidentiality and ensuring audio and visual privacy
• Offering a wide range of contraceptive methods
• Providing free or subsidized services

Investments that contribute to building an enabling environment for adolescent programming often include: ensuring legal rights, policies, and guidelines that respect, protect, and fulfill adolescents’ human rights to contraceptive information, products, and services regardless of age, sex, marital status, or parity; addressing norms and fostering support among communities and parents for adolescents to access contraceptive information and services; and addressing gender norms.

Taken together, these seven elements of adolescent-friendly contraceptive services, encompassing service delivery and enabling environment aspects, need to be considered to increase adolescent uptake of contraception. Based on experience from implementing stand-alone and separate-space AFCS, streamlining these elements into existing contraceptive services has the potential to be both cost-effective and scalable, expanding the reach of existing programs and improving access to high-quality contraceptive services for adolescents (see Figure 1).

This brief focuses on the elements of AFCS that are typically implemented within a service delivery setting. It describes how mainstreaming AFCS can address key challenges for contraceptive programs, discusses the existing evidence of adolescent-friendly elements, outlines key issues for planning and implementation, and identifies knowledge gaps. This brief does not fully cover elements that contribute to the enabling environment for adolescent programming, which are addressed more completely in other High-Impact Practice (HIP) briefs, such as the briefs on health communication and policy.

AFCS has been identified as an enhancement to high-impact practices in family planning by the HIP technical advisory group. An “enhancement” is a practice that can be implemented in conjunction with HIPs to further intensify the impact of the HIPs. While there are some initial experiences implementing mainstreamed AFCS, more research and documentation is needed to better understand the potential and limitations of this approach. For more information about HIPs, see https://www.fphighimpactpractices.org/overview.

Studies consistently show that sexually active adolescents (married or unmarried) face many barriers to obtaining contraceptive services and products to prevent pregnancy—whether to delay, space, or limit pregnancy (Abdul-Rahman et al., 2011; Bankole and Malarcher, 2010; Biddlecom et al., 2007; ChandraMouli et al., 2014; Decker and Constantine, 2011; Glinski et al., 2014; Godia et al., 2014; Sidze et al., 2014; Tylee et al., 2007). Addressing these barriers within programs and policies is likely to improve the quality of services for all people who need contraception and is of particular importance to adolescents. These barriers are well documented and include:

Provider biases. Providers who believe that adolescents should not be sexually active or that contraception may inhibit future fertility may refuse to serve young people, or they may restrict access to certain contraceptive methods (Warenius et al., 2006; Wood and Jewkes, 2006). For example, in one survey in India, a third of doctors, more than half of nurses, and more than two-fifths of midwives stated they would deny oral contraceptives based on age, and nearly half of doctors said they would deny injectables based on age (Calhoun et al., 2013). In Ethiopia, nearly half of surveyed providers reported negative attitudes about providing contraception to unmarried adolescents (Tilahun et al., 2012).

Lack of confidentiality and privacy. Studies with adolescents from a range of countries including Mongolia, Vanuatu, and Zimbabwe indicate that confidentiality and privacy are very important concerns with accessing contraceptive services (Erulkar et al., 2005; Kennedy et al., 2013; Sovd et al., 2006). In Malawi, in a national representative sample of sexually active adolescents aged 12 to 19, more than 20% of females and 10% of males stated their privacy was not respected, which they perceived as a barrier to accessing services (Biddlecom et al., 2007).

Few contraceptive options. Adolescent programs often focus on provision of barrier methods (mostly condoms) and other short-acting contraceptives. Long-acting reversible contraceptives (LARCs) are often not presented as options for adolescents (Eke and Alabi-Isama, 2011). This restriction is usually due to provider bias or lack of awareness that age and parity are not contraindications for any method, according to the World Health Organization’s medical eligibility criteria for contraceptive use (WHO, 2015). Users of short-acting methods, particularly adolescents aged 15 to 19, are more prone to contraceptive failure than users of LARCs (Blanc et al., 2009).

Financial barriers. Adolescents are unlikely to have control over financial resources to pay for transportation and service fees to access services (Michaels-Igbokwe et al., 2014). Studies with youth ages 15 to 24 in many low- and middle-income countries, such as Brazil, China, India, Kenya, Nigeria, and Uganda, found that cost is a barrier for accessing contraceptive, reproductive health, or health services (Bankole & Malarcher, 2010; Santhya et al., 2014; Warner et al., 2013). A survey of youth of the same age group in Myanmar found that fewer than one in five could afford reproductive health services (Thin Zaw et al., 2012).

Legal and policy barriers. A number of studies document legal and policy-related barriers including laws that do not allow contraception for adolescents and lack of knowledge among providers and adolescents themselves of the legal rights of adolescents to obtain contraception (Apland, 2014; Cook & Dickens, 2000; IPPF, 2014; Jaruseviciene, et al., 2006; Jaruseviciene et al., 2014; Levy et al. 2001; UNESCO et al., 2013). For example, in a study in Uganda, 38% of public and private providers stated that they required a consent form either from a parent, a spouse, or both for clients under 18 years of age requesting contraceptives (Nalwadda et al., 2011).

Gender norms. Gender norms that idealize sexual ignorance for girls and sexual prowess for boys are found globally and can impede young people’s access to information and services and their ability to negotiate sexual relationships (Gay et al., 2012; Santhya & Jejeebhoy, 2015). Providers often reinforce these inequitable gender norms by refusing to provide unmarried adolescent girls with contraception even when requested (ChandraMouli et al., 2014). Married adolescent girls often face different gender-related barriers due to their social isolation, lack of power, limited mobility, and pressures to prove fertility by becoming pregnant early and often (Adams et al., 2013; Greene et al., 2014; Singh et al., 2014). As a way of upholding these social and gender norms, providers may not provide contraception to married adolescent girls or restrict long-acting methods until they have had a child (Greene et al., 2014; Speizer et al., 2000). Young men are expected to be knowledgeable about sex, making it difficult for them to seek information, and they may also face structural barriers to accessing services, which are typically targeted to women (Barker et al., 2007; Kuene et al, 2004; UNFPA, 2000).

Failure to address issues such as women’s lower social status, economic dependence and limited agency, transactional sex as an important economic resource for young girls, and social norms of masculinity was identified as one reason a large service delivery improvement effort in Tanzania failed to demonstrate an impact on contraceptive use among young people (Doyle et al., 2011; Wight et al., 2012).

Of six studies that assessed contraceptive use among adolescents post-AFCS intervention compared with a similar unexposed or control group, five found a statistically significant increase in contraceptive use among females exposed to or in the intervention group compared with females in the unexposed or control group (see Table 1). All these programs targeted both males and females, including individuals aged 15 to 19. While all programs included some AFCS elements discussed in this brief, only some included all of them. (In some countries, there may not have been a need to address all seven AFCS elements, for example, if certain elements were already in place.) The one study that did not find a statistically significant increase was in Nicaragua among a generalized population of voucher receivers. However, when the Nicaragua study population was disaggregated, findings indicated that voucher receivers in the school-based intervention group were more than twice as likely to report contraceptive use as school-based non-voucher receivers (Meuwissen et al., 2006). Of the five studies that reported male contraceptive use separately, only the program in China showed a significant increase in male contraceptive use (Lou et al., 2004).

In addition to programs included in Table 1, evidence from India, Mozambique, Tanzania, and Zimbabwe demonstrates a positive effect of AFCS programming on adolescent contraceptive use (Chandra-Mouli et al., 2015; Chandra-Mouli et al., 2013; Kanesathasan et al., 2008; Kim et al., 2001). Findings from these studies are consistent with other literature reviews, which conclude that effective adolescent programs usually involve investments in service delivery and enabling environment elements (Denno et al., 2015; Ehlers, 2003; Gottschalk & Ortalyi, 2014; Hainsworth et al., 2014; Hindin & Fatusi, 2014; Kesterton & de Mello, 2010; Williamson et al., 2009).

Many of the study reports included little or no detail on the degree of implementation or on intermediate results. Therefore, it is unclear which elements specifically contributed to observed increases in contraceptive use. It is also important to note that half of the studies included in Table 1 were implemented at small scale and in most cases were not sustained.

Interventions with insufficient evidence of impact on adolescent’s contraceptive use:

• Youth clubs and youth centers that provide contraceptive services may not be cost-effective and do not reach the intended target groups (Chandra-Mouli et al., 2015b; Denno et al., 2015; Zuurmond et al., 2012).
• Benefits of peer educator programs are typically limited to those trained as peer educators (Chandra-Mouli et al., 2015b; Harden et al., 2001; Kim & Free, 2008; Tolli, 2012).

Conduct a needs assessment to identify the most effective approaches to reaching sexually active adolescents with contraceptive services. Formative research and monitoring data should be disaggregated to identify specific needs and preferences of different adolescent groups. Take into account where adolescents currently go to access contraceptive commodities and services and who has unmet need. Sub-populations may demonstrate preferences for specific channels, such as the public or private sector, clinics, or pharmacies.

Use multiple service modalities to reach a wider range of adolescents. Such approaches can include static facilities (both public and private), community-based distribution, mobile outreach services, pharmacies and drug shops, informal settings, schools, or workplace-based services.

Train providers to offer adolescent-friendly services. Include AFCS elements into pre-service training for providers. This inclusion can reduce the need for in-service training while ensuring recent graduates have basic competencies in adolescent health and contraceptive service delivery. While training is a core and necessary element in effective AFCS programs, it is not sufficient on its own to change provider behavior (Denno et al., 2015). Training should include providing nonjudgmental information and services; accurate information on medical eligibility criteria for adolescent contraceptive use; legal policies and rights of adolescents to services and information; values clarification on adolescent sexuality; and skills on how to communicate with adolescent clients.

Use a whole-clinic approach to training on AFCS. This approach will help ensure adolescent-friendly care is not invested in only one provider and that adolescents do not experience resistance from support staff, such as an intake nurse or pharmacist.

Reinforce training through supportive supervision, job aids, and mentorship to change provider attitudes and behaviors. Supportive supervision tools and provider job aids can be helpful to enforce rights-based programming.

Enforce confidentiality and ensure audio and visual privacy. Take various steps to increase client confidentiality such as: safe storage of client records, nondisclosure of adolescents’ health information without their permission; minimizing nonessential interruptions by other facility staff or clients during service provision; and reinforcing the importance of client confidentiality as part of AFCS training. Various measures can be taken to help maintain audio and visual privacy, such as using a private counseling room, using consultation rooms with doors and window curtains, partitioning the waiting areas so that adolescent clients do not have to mix with adult clients, and not conducting history taking and screening in public.

Tailor health communication to the needs and interests of adolescents. Consider where and from whom adolescents get information on sexual and reproductive health. Engage young people in developing messaging and in identifying appropriate channels for communication. (See also the Health Communication and mHealth HIP briefs.)

Offer a full range of contraceptive options. Figure 2 shows method mix among 15- to 19-year-old females in Bangladesh, the Dominican Republic, and Sierra Leone. Modern contraceptive use among adolescents in these three countries ranges from 21% to 42%. The data illustrate that adolescents will use a variety of methods, including highly effective LARCs when offered a full range of contraceptive methods (AAP, 2014; Committee on Adolescent Health Care, 2012; WHO, 2015).

Provide no-cost or subsidized services. All programs should have some means to provide services and contraceptives free or at highly subsidized rates. Programs have used a variety of approaches to accomplish this including subsidized services as part of a social franchise model, social marketing, or vouchers, or as part of a cost-recovery scheme (Denno et al., 2015). Programs that intend to reach adolescents should develop targeted marketing and distribution strategies for this population.

Provide an enabling environment by ensuring legal rights and supportive policies related to provision of contraceptive services for adolescents. Clear guidelines that support health professionals to provide services and information to adolescents are critical for expanding adolescents’ access to services. For legal rights and adolescent-related health policies to be operationalized at the service delivery level, the facility should have copies of relevant service delivery policies and standards (e.g., adolescent-friendly service provision standards where they exist) and providers should be well oriented on their use as part of AFCS training or staff updates. In addition, supervision checklists should reflect key provisions of these policies, and supervisors should reinforce their application during supervision visits (Greifnger & Ramsey, 2014; Senderowitz et al., 2002).

Link service delivery improvements with activities that build support within communities. Interventions directed at influencing the sexual and reproductive health behaviors of adolescents are significantly enhanced where there are complementary interventions for parents, providers, religious leaders, and other influential adults who can foster a supportive environment in health facilities, schools, religious places of worship, and in homes (Futures Group International, 2005; Gottschalk & Ortayli, 2014; Kesterton & de Mello, 2010). Effective sexuality education guidelines (UNESCO, 2009a; UNESCO, 2009b) can ensure adequate knowledge by adolescents to access services (Todesco & Gay, forthcoming 2015).

Pay attention to gender and social norms to ensure successful investments in AFCS. Adolescent girls will access contraception in settings where gender norms have been transformed to allow girls to know about sexual and reproductive health and to feel empowered to access services (McCleary-Sills et al., 2012). Adolescent boys will access contraception in settings where boys feel some sense of responsibility to plan pregnancies (Barker et al., 2010).

For more information about High-Impact Practices in Family Planning (HIPs), please contact the HIP team.

Abdul-Rahman L, Marrone G, Johansson A. Trends in contraceptive use among female adolescents in Ghana. Afr J Reprod Health. 2011;15(2):45-55. Available from: http://www.bioline.org.br/pdf?rh11019

Adams MK, Salazar E, Lundgren R. Tell them you are planning for the future: gender norms and family planning among adolescents in northern Uganda. Int J Gynaecol Obstet. 2013;123 Suppl 1:e7-e10. Available from: http://dx.doi.org/10.1016/j.ijgo.2013.07.004

American Academy of Pediatrics (AAP), Committee on Adolescence. Policy statement: contraception for Adolescents. Pediatrics. 2014;134(4):e1244-e1256. Available from: http://dx.doi.org/10.1542/peds.2014-2299

Apland K. Over-protected and under-served: a multi-country study on legal barriers to young people’s access to sexual and reproductive health services: El Salvador case study. London: International Planned Parenthood Federation; 2014. Available from: http://www.childrenslegalcentre.com/userfiles/file/ippf_coram_el_salvador_report_eng_web.pdf

Bankole A, Malarcher S. Removing barriers to adolescents’ access to contraceptive information and services. Stud Fam Plann. 2010;41(2):117-124.

Bankole A, Singh S. In their own right: addressing the sexual and reproductive health needs of men worldwide. New York: Alan Guttmacher Institute; 2003. Available from: http://www.guttmacher.org/pubs/itor_intl.pdf

Barker G, Ricardo C, Nascimento M, Olukoya A, Santos C. Questioning gender norms with men to improve health outcomes: evidence of impact. Glob Public Health. 2010; 5(5):539-553.

Barker G, Ricardo C, Nascimento M. Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Geneva: World Health Organization; 2007. Available from: http://www.who.int/gender/documents/Engaging_men_boys.pdf

Bhuiya, I, Rob U, Chowdhury AH, Khan ME, Rahman L, Adamchak SE. Improving sexual and reproductive health of female adolescents in Bangladesh by providing information and services. Popul Rev. 2006;45(2):60-71.

Biddlecom AE, Munthali A, Singh S, Woog V. Adolescents’ views of and preferences for sexual and reproductive health services in Burkina Faso, Ghana, Malawi and Uganda. Afr J Reprod Health. 2007;11(3):99-110. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367115/pdf/nihms42619.pdf

Blanc AK, Tsui AO, Croft TN, Trevitt JL. Patterns and trends in adolescents’ contraceptive use and discontinuation in developing countries and comparisons with adult women. Int Perspect Sexual Reproduct Health. 2009;35(2):63- 71. Available from: https://www.guttmacher.org/pubs/journals/3506309.html

Calhoun LM, Speizer IS, Rimal R, Sripad P, Chatterjee N, Achyut P, et al. Provider imposed restrictions to clients’ access to family planning in urban Uttar Pradesh, India: a mixed methods study. BMC Health Services Research. 2013;13:532. Available from: http://dx.doi.org/10.1186/1472-6963-13-532

Chandra-Mouli V, Gibbs S, Badiana R, Quinhas F, Svanemyr J. Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reprod Health. 2015;12:12. Available from: http://dx.doi.org/10.1186/1742-4755-12-12

Chandra-Mouli V, Lane C, and Wong S. What does not work in adolescent sexual and reproductive health: A review of evidence on interventions commonly accepted as best practices. 2015b; Global Health Science and Practice. http://www.ghspjournal.org/content/3/3/333.full.pdf+html

Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G. Contraception for adolescents in low and middle income countries: needs, barriers, and access. Reprod Health. 2014; 11(1):1. Available from: http://dx.doi.org/10.1186/1742-4755-11-1

Chandra-Mouli V, Mapella E, John T, Gibbs S, Hanna C, Kampatibe N, et al. Standardizing and scaling up quality adolescent friendly health services in Tanzania. BMC Public Health. 2013;13:579. Available from: http://dx.doi.org/10.1186/1471-2458-13-579

Committee on Adolescent Health Care, Long-Acting Reversible Contraception Working Group; The American College of Obstetrics and Gynecology (ACOG). Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Washington, DC: ACOG; 2012. Available from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-andLong-Acting-Reversible-Contraception

Cook R, Dickens BM. Recognizing adolescents’ ‘evolving capacities’ to exercise choice in reproductive healthcare. Int J Gynaecol Obstet. 2000;70(1):13-21.

Decker M, Constantine NA. Factors associated with contraceptive use in Angola. Afr J Reprod Health. 2011;15(4):68-77. Available from: http://www.bioline.org.br/pdf?rh11053

Denno DM, Hoopes AJ, Chandra-Mouli V. Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support. J Adol Health. 2015;56(Suppl 1):S22-S41. Available from: http://dx.doi.org/10.1016/j.jadohealth.2014.09.012

Doyle AM, Weiss HA, Maganja K, Kapiga S, McCormack S, Watson-Jones D, et al. The long-term impact of the MEMA kwa Vijana adolescent sexual and reproductive health intervention: effect of dose and time since intervention exposure. PLoS One. 2011;6(9):e24866. Available from: http://dx.doi.org/10.1371/journal.pone.0024866

Ehlers VJ. Adolescent mothers’ utilization of contraceptive services in South Africa. Int Nursing Rev. 2003;50(4):229-241.

Eke AC, Alabi-Isama L. Long-acting reversible contraception (LARC) use among adolescent females in secondary institutions in Nnewi, Nigeria. J Obstet Gynaecol. 2011;31(2):164-168.

Erulkar AS, Onoka CJ, Phiri A. What is youth-friendly? Adolescents’ preferences for reproductive health services in Kenya and Zimbabwe. Afr J Reprod Health. 2005;9(3):51-58. Available from: http://www.bioline.org.br/pdf?rh05039

Erulkar AS and Tamrat T. Evaluation of a reproductive health program to support adolescent girls in rural Ethiopia. Afr J Reprod Health. 2014;18(2):68-76. Available from: http://www.bioline.org.br/pdf?rh14026

Evens E, Otieno-Masaba R, Eichleay M, McCarraher D, Hainsworth G, Lane C, et al. Post-abortion care services for youth and adult clients in Kenya: a comparison of services, client satisfaction and provider attitudes. J Biosoc Sci. 2014;46(1):1-15. Available from: http://www.pathfinder.org/publications-tools/pdfs/post-abortion-care-service-for-youth-and-adult-clients-in-kenya.pdf.

Futures Group International. Jamaica adolescent reproductive health activity: end of project report. Washington, DC: Futures Group International; 2005.

Gay J, Croce-Galis M, Hardee K. What works for women and girls: evidence for HIV/AIDS interventions.2nd edition. Washington, DC: Futures Group, Health Policy Project; 2012. Available from: http://www.whatworksforwomen.org

Glinski A, Sexton M, Petroni S. Adolescents and family planning: what the evidence shows. Washington, DC: International Center for Research on Women; 2014. Available from: https://www.icrw.org/wp-content/uploads/2016/10/140701-ICRW-Family-Planning-Rpt-Web.pdf

Godia PM, Olenja JM, Hofman JJ, van den Broek N. Young people’s perception of sexual and reproductive health services in Kenya. BMC Health Serv Res. 2014;14:172. Available from: http://dx.doi.org/10.1186/1472-6963-14-172

Gottschalk LB, Ortayli N. Interventions to improve adolescents’ contraceptive behaviors in low- and middle-income countries: a review of the evidence base. Contraception 2014;90(3):211-225.

Greene ME, Gay J, Morgan G, Benevides R, Fikree F. Literature review: reaching young first-time parents for the healthy spacing of second and subsequent pregnancies. Washington, DC: Pathfinder International, Evidence to Action Project; 2014. Available from: http://www.e2aproject.org/publications-tools/pdfs/reaching-first-time-parents-for-pregnancy-spacing.pdf

Greifinger R, Ramsey M. Making your health services youth-friendly: a guide for program planners and implementers. Washington, DC: Population Services International and IntraHealth International; 2014. Available from: http://www.psi.org/publication/making-your-healthservices-youth-friendly-a-guide-for-program-planners-and-implementers/

Hainsworth G, Engel DM, Simon C, Rahimtoola M, Ghiron LJ. Scale-up of adolescent contraceptive services: lessons from a 5-country comparative analysis. J Acquir Immune Defic Syndr. 2014;66 Suppl 2:S200-S208.

Harden A, Oakley A, Oliver S. Peer-delivered health promotion for young people: a systematic review of different study designs. Health Educ J. 2001;60(4):339-353.

Hindin MJ, Fatusi A. Final report: exploration of young people’s sexual and reproductive health assessment practices. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health; 2014. Available from: http://www.jhsph.edu/departments/population-family-and-reproductivehealth/focal-areas/_pdfs/Exploration_of_Young_Peoples_Sexual_and_Reproductive_Health_Assessment_Practices_Final.pdf

High-Impact Practices in Family Planning (HIPs). Family planning high-impact practice list. Washington, DC: USAID; 2014. Available from: https://www.fphighimpactpractices.org/high-impact-practices-in-family-planning-list

International Planned Parenthood Federation (IPPF). Over-protected and under-served: A multi-country study on legal barriers to young people’s access to sexual and reproductive health services. London: IPPF; 2014. Available from: http://www.ippf.org/sites/default/files/ippf_coram_uk_report_web.pdf

Jaruseviciene L, Zaborskis A, Lazarus JV. Public expectations concerning confidentiality protection of adolescents’ sexual and reproductive health care in Lithuania: findings of the surveys conducted in 2005 and 2012. Eur J Contracept Reprod Health Care. 2014;19(2):102-107.

Jaruseviciene L, Levasseur G, Liljestrand J. Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners. Reprod Health Matters. 2006;14(27):129-137.

Kanesathasan A, Cardinal LJ, Pearson E, Das Gupta S, Mukherjee S, Malhotra A. Catalyzing change: improving youth sexual and reproductive health through DISHA, an integrated program in India. Washington, DC: International Center for Research on Women; 2008. Available from: http://www.icrw.org/files/publications/Catalyzing-Change-Improving-Youth-Sexual-and-Reproductive-Health-Through-disha-an-IntegratedProgram-in-India-DISHA-Report.pdf

Kennedy EC, Bulu S, Harris J, Humphreys D, Malverus J, Gray NJ. “Be kind to young people so they feel at home”: a qualitative study of adolescents’ and service providers’ perceptions of youth-friendly sexual and reproductive health services in Vanuatu. BMC Health Serv Res. 2013;13:455. Available from: http://dx.doi.org/10.1186/1472-6963-13-455

Kesterton AJ, de Mello M. Generating demand and community support for sexual and reproductive health services for young people: a review of the literature and programs. Reprod Health. 2010;7:25. Available from: http://dx.doi.org/10.1186/1742-4755-7-25

Kim CR, Free C. Recent evaluations of the peer‐led approach in adolescent sexual health education: a systematic review. Perspect Sexual Reprod Health. 2008;40(3):144-151. Available from: http://dx.doi.org/10.1363/4014408

Kim YM, Kols A, Nyakauru R, Marangwanda C, Chibatamoto P. Promoting sexual responsibility among young people in Zimbabwe. Int Family Plann Perspect. 2001;27(1):11-19. Available from: http://www.guttmacher.org/pubs/journals/2701101.pdf

Kuene B, Beksinska M, Zondi S, Mthembu N, Mullick S, Ottolenghi E, et al. Involving men in maternity care: South Africa. Durban (South Africa): University of Witwatersrand; 2004. Co-published by Population Council and Family Health International. Available from: http://pdf.usaid.gov/pdf_docs/Pnada931.pdf

Levy BM, Hardee K, Subaran S. Analysis of the legal, regulatory, and policy environment for adolescent reproductive health in Jamaica. Youth.now; 2001. Available from: http://pdf.usaid.gov/pdf_docs/PNACY162.pdf

Lou CH, Wang B, Shen Y, Gao ES. Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai. J Adol Health. 2004;34(5):433-440.

McCleary-Sills J, Mcgonagle A, Malhotra A. Women’s demand for reproductive control: understanding and addressing gender barriers. Washington, DC: International Center for Research on Women; 2012. Available from: http://www.icrw.org/sites/default/files/publications/Womens-demand-for-reproductive-control.pdf

Meuwissen LE, Gorter AC, Knottnerus AJA. Impact of accessible sexual and reproductive health care on poor and underserved adolescents in Managua, Nicaragua: a quasi-experimental intervention study. J Adol Health. 2006c;38(1):56.

Michaels-Igbokwe C, Lagarde M, Cairns J, Terris-Prestholt F. Using decision mapping to inform the development of a stated choice survey to elicit youth preferences for sexual and reproductive health and HIV services in rural Malawi. Soc Sci Med. 2014;105:93-102.

Nalwadda G, Mirembe F, Tumwesigye NM, Byamugisha J, Faxelid E. Constraints and prospects for contraceptive service provision to young people in Uganda: providers’ perspectives. BMC Health Serv Res. 2011;11:220. Available from: http://dx.doi.org/10.1186/1472-6963-11-220

Santhya KG, Jjeebohoy SJ. Sexual and reproductive health and rights of adolescent girls: evidence from low- and middle-income countries. Glob Public Health. 2015;10(2):189-221. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318087/

Santhya KG, Prakash R, Jejeebhoy SJ, Singh SK. Accessing adolescent friendly health clinics in India: the perspectives of adolescents and youth. New Delhi: Population Council; 2014. Available from: http://www.popcouncil.org/uploads/pdfs/2014PGY_AFHC-IndiaReport.pdf

Senderowitz J. Making reproductive health services youth friendly. Washington, DC: Focus on Young Adults, Pathfinder International; 1999. Available from: http://www.pathfinder.org/publications-tools/pdfs/Making-Reproductive-Health-Services-Youth-Friendly.pdf

Senderowitz J, Solter C, Hainsworth G. Clinic assessment of youth friendly services: a tool for assessing and improving reproductive health services for youth. Watertown, MA: Pathfinder International; 2002. Available from: http://www2.pathfinder.org/site/DocServer/mergedYFStool.pdf?docID=521

Sidze EM, Lardoux S, Speizer IS, Faye CM, Mutua MM, Badji F. Young women’s access to and use of contraceptives: the role of providers’ restrictions in urban Senegal. Int Perspect Sex Reprod Health. 2014;40(4):176-183. Available from: http://dx.doi.org/10.1363/4017614

Singh S, Darroch JE, Ashford LS. Adding it up: the costs and benefits of investing in sexual and reproductive health 2014. New York: Guttmacher Institute; 2014. Available from: http://www.guttmacher.org/pubs/AddingItUp2014.pdf

Sovd T, Mmari K, Lipovsek V, Manaseki-Holland S. Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent friendly health services in Mongolia. J Adolesc Health. 2006;38(5):519-526.

Speizer IS, Hotchkiss DR, Magnani RJ, Hubbard B, Nelson K. Do service providers in Tanzania unnecessarily restrict clients’ access to contraceptive methods? Int Family Plann Perspect. 2000;26(1):13-20, 42. Available from: https://www.guttmacher.org/pubs/journals/2601300.pdf

Thin Zaw PP, Liabsuetrakul T, Htay TT, McNeil E. Equity of access to reproductive health services among youths in resource-limited suburban communities of Mandalay City, Myanmar. BMC Health Serv Res. 2012;12:458. Available from: http://dx.doi.org/10.1186/1472-6963-12-458

Tilahun M, Mengistie B, Egata G, Reda AA. Health workers’ attitudes toward sexual and reproductive health services for unmarried adolescents in Ethiopia. Reprod Health. 2012;9:19. Available from: http://dx.doi.org/10.1186/1742-4755-9-19

Todesco M, Gay J. Early and unintended pregnancy: global guidance for an education sector response. Paris: UNESCO; Forthcoming 2015.

Tolli M. Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: a systematic review of European studies. Health Educ Res. 2012;27(5):904-913. Available from: http://dx.doi.org/10.1093/her/cys055

Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet. 2007;369(9572):1565-1573.

United Nations Children’s Fund (UNICEF). The state of the world’s children 2011. Adolescence: an age of opportunity. New York: UNICEF; 2011. http://www.unicef.org/sowc2011/

United Nations Educational, Scientific and Cultural Organization (UNESCO). International technical guidance on sexuality education: an evidence-informed approach for schools, teachers and health educators. Volume 1: the rationale for sexuality education. Paris: UNESCO; 2009a. Available from: http://data.unaids.org/pub/ExternalDocument/2009/20091210_international_guidance_sexuality_education_vol_1_en.pdf

United Nations Educational, Scientific and Cultural Organization (UNESCO). UNESCO’s short guide to essential characteristics of effective HIV prevention. Paris: UNESCO; 2009b . Available from: http://unesdoc.unesco.org/images/0018/001885/188528e.pdf

United Nations General Assembly. Convention on the Rights of the Child, G.A. Res. 44/25 of 20 Nov 1989 (Sep. 2, 1990). Available from: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx

United Nations Population Fund (UNFPA). State of the world population 2014. The power of 1.8 billion: adolescent, youth and the transformation of the future. New York: UNFPA; 2014. Available from: https://www.unfpa.org/sites/default/files/pub-pdf/EN-SWOP14-Report_FINAL-web.pdf

United Nations Population Fund (UNFPA). State of the world population 2012. By choice not by chance family planning, human rights and development. New York: UNFPA; 2012. Available from: http://eeca.unfpa.org/publications/state-world-population-2012-report

United Nations Population Fund (UNFPA). Partnering: a new approach to sexual and reproductive health. New York: UNFPA; 2000. Available from: http://www.unfpa.org/publications/partnering-new-approach-sexual-and-reproductive-health

United Nations Population Division (UNPD). World Population Estimates. The 2015 Revision. http://esa.un.org/unpd/wpp/DataQuery/ visited September 1, 2015.

Warenius LU, Faxelid EA, Chishimba PN, Musandu JO, Ong’any AA, Nissen EB. Nurse-midwives’ attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Reprod Health Matters. 2006;14(27):119-128.

Warner A, Hollingworth G, Thompson L, Petroni S, Sexton M, Song J, et al. I know. I want. I dream. Girls’ insights for building a better world. Washington, DC: International Center for Research on Women; 2013. Available from: http://www.icrw.org/sites/default/files/publications/Pages-%20Girl%20Insights%20Report%20FINAL.pdf

Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, et al. Sexual behaviour in context: a global perspective. Lancet. 2006;368(9548):1706-1728.

Wight D, Plummer M, Ross D. The need to promote behaviour change at the cultural level: one factor explaining the limited impact of the MEMA kwa Vijana adolescent sexual health intervention in rural Tanzania. A process evaluation. BMC Public Health. 2012;12:788. Available from: http://dx.doi.org/10.1186/1471-2458-12-788

Williams T, Mullen S, Karim A, Posner J. Evaluation of the African youth alliance program in Ghana, Tanzania, and Uganda: impact on sexual and reproductive health behavior among young people. Arlington, VA: John Snow, Inc; 2007. Available from: http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=4645&lid=3

Williamson LM, Parkes A, Wight D, Petticrew M, Hart GJ. Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research. Reprod Health. 2009;6:3. Available from: http://dx.doi.org/10.1186/1742-4755-6-3

Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reprod Health Matters. 2006;14(27):109-118.

World Health Organization (WHO). Medical eligibility criteria for contraceptive use. Fifth edition. Geneva: WHO; 2015. Available from: http://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/

Zuurmond MA, Geary RS, Ross DA. The effectiveness of youth centers in increasing use of sexual and reproductive health services: a systematic review. Stud Fam Plann. 2012;43(4):239-254.

High-Impact Practices in Family Planning (HIPs). Adolescent-friendly contraceptive services: mainstreaming adolescent-friendly elements into existing contraceptive services. Washington (DC): USAID; 2015. Available from: https://www.fphighimpactpractices.org/briefs/adolescent-friendly-contraceptive-services

This document was written by Jill Gay, Gwyn Hainsworth, Karen Hardee, and Shawn Malarcher. Critical review and helpful comments were provided by Michal Avni, Regina Benevides, Doortje Braeken, Jimmie Braley, Kimberly Cole, Maureen Corbett, Liz Creel, Laurette Cucuzza, Jen Drake, Ellen Eiseman, Sarah Fox, Kate Gilles, Rena Greifinger, Jim Griffin, Rachel Hampshire, Ann Hirschey, Laura Hoemeke, Laura Hurley, June Hutchings, Roy Jacobstein, Niranjala Kanesathasan, Rebecca Kohler, Joan Kraft, Cate Lane, Pauline Lee, Judy Manning, Erin Mielke, Stembile Mugore, Danielle Murphy, Constance Newman, Rachel Okun-Kozlowicki, Tanvi Pandit-Rajani, Leslie Patykewich, Anne Pitzer, Jen Pope, Shannon Pryor, James Shelton, Tabitha Sripipatana, Sara Stratton, Julie Taft, Caitlin Thistle, Mary Vandenbroucke, Gracey Vaughn, Chandra-Mouli Venkatraman, Defa Wane, Kelsey Wright, and Sylvia Wong.

This HIP brief is endorsed by: Abt Associates, Bill & Melinda Gates Foundation, CARE, Chemonics International, EngenderHealth, FHI 360, Georgetown University/Institute for Reproductive Health, International Planned Parenthood Federation, IntraHealth International, Jhpiego, John Snow, Inc., Johns Hopkins Center for Communication Programs, Management Sciences for Health, Marie Stopes International, Palladium, PATH, Pathfinder International, Planned Parenthood Global, Population Council, Population Reference Bureau, Population Services International, Public Health Institute, Save the Children, U.S. Agency for International Development, and University Research Co., LLC.

The World Health Organization/Department of Reproductive Health and Research has contributed to the development of the technical content of HIP briefs, which are viewed as summaries of evidence and field experience. It is intended that these briefs be used in conjunction with WHO Family Planning Tools and Guidelines: http://www.who.int/topics/family_planning/en/.