By: Brian Mulligan, G. Yvette Ribaira, and Elaine E. Rossi (JSI Research & Training Institute Inc) and Peter Gottert (FHI360)

1. Background and rationale for the intervention 

Access to reproductive health information and family planning services remains a significant global challenge. An estimated 214 million women of reproductive age in developing countries have an unmet need for contraception, primarily because they lack access to information, education, and contraceptive services (1). Unmet family planning (FP) needs are highest in Africa, where an estimated one-third of women of reproductive age have an unmet need for modern contraception (2). The reproductive needs of adolescents and youth in particular are consistently high.  Specifically in Sub-Saharan Africa, an estimated 62 percent of adolescent women ages 15 to 19 cannot satisfy their need for contraception (3).  Community Health Workers (CHWs) and Community Health Volunteers (CHVs) can help to improve this situation.

Madagascar has a particularly high adolescent fertility rate with 108 births per 1,000 women aged 15 to 19, compared to the global average of 42 per 1,000 (4).  The Government of Madagascar (GOM) recognizes early marriage as a form of gender-based violence (GBV), and promulgated a law in 2007 setting the minimum legal age for marriage at 18 years (5). Despite this law, child marriage remains widespread, and Madagascar has the 13th highest prevalence rate of child marriage in the world with 41% of girls married by age 18 (6,7).      

Many countries have adopted family planning strategies, including specific interventions for adolescents to meet goals of universal health coverage and lower mortality rates among young women and their children. The GOM has adopted family planning (FP) as an important strategy to improve adolescent and youth health and reduce maternal mortality. The Madagascar “National Reproductive Health and Family Planning Law” and “National Strategic Plan for Adolescent and Youth Reproductive Health” address reproductive choice and the negative consequences of early childbearing. However, past youth-     focused interventions have been limited in terms of overall impact. Many have focused on the establishment of designated spaces for youth; for example, health centers designed as multifunctional youth friendly spaces where adolescents and young people can access information on sexual and reproductive health, as well as take part in educational and recreational youth health focused activities. However, the contributions of these youth spaces have been minimal, with program evaluations showing that very few young people were aware of their existence and even fewer had used them (8).

In an effort to increase access to and use of family planning by youth, the USAID Community Capacity for Health Program (CCHP, 2016-2021) decided to focus on the needs of youth.   The Program, which operated in seven regions of Madagascar, covering 4,708 villages with a total population of 6.6 million people, provided tools and capacity-building training to about 10,000 Community Health Volunteers (CHVs) who provide basic maternal health, child health, and family planning services.  The Program was a collaborative effort between Madagascar’s Ministry of Public Health (MOPH), USAID, and JSI Research & Training Institute, Inc. (JSI).  The CHVs are at the heart of the program and are essential to quality FP counseling and services, especially in remote areas.

2. Approach

CCHP adopted a youth-centered approach, reaching them where they spend most of their time: sharing information at school through peer educators or in the community through youth networks. These efforts focused on preventing early or unwanted pregnancies, engaging boys and young men in health activities, and raising awareness and empowering youth in the fight against GBV. With a clear focus on youth across its community interventions, CHVs and youth peer educators contributed to progress toward the GOM FP 2020 goals, which included: 

1. increasing the contraceptive prevalence rate from 33 percent in 2013 to 50 percent in 2020, and 
2. reducing the rate of unmet need for FP from 17.8 percent in 2013 to 9 percent in 2020.

Youth activities were designed to promote adoption of important life skills and healthy behaviors using various communications channels. Youth—like all people— are more likely to adopt healthy behaviors when they receive the same message on multiple occasions. The comprehensive approach enabled youth to make responsible life choices on sensitive reproductive health and FP issues.  CHVs provided basic FP services and referrals to reproductive health and long-term FP services in health posts or during home visits.  In communities where there were active youth health peer educators (YPEs), they were linked directly to CHVs in their communities who wanted to serve adolescents.  This approach for youth engaged them by providing key health messages through several unique and complementary activities which CHWs can use to design actions for their communities:

     1) Five Life Skills: An experiential learning program for in-school and out-of-school youth led by youth peer educators (YPE) (9);

     2) Model and Mentor Families (10): A community-wide approach with targeted messages for youth. The Program’s Model and Mentor Families approach worked to expand the promotion of improved health behaviors from household to household, allowing families that became Mentor Families to become important health leaders in the community;     

3) FP Invitation Cards: Cards shared by young people who are current FP users with their networks of family and friends; this links to the Life Skills “Making good Decisions” and “Increasing Self-confidence;”

     4) Key Message Dissemination: CHVs, community leaders, and radio broadcasts address the prevention of early marriage, early pregnancy, and GBV.

3. Results 

Youth were actively engaged in CCHP’s programming, including shaping, and implementing activities with their peers and interacting with CHVs. Youth who participated in the Program were vested in the results. Overall, the Program saw an increase in the number of new FP users under the age of 25 over the course of the CCHP project,  almost all served primarily or exclusively by CHVs. By the end of the project, 74 percent of regular FP users were between the ages of 10–24. Specific achievements include:

• Cross-sectoral engagement: CHWs can find local resources and advocates for youth work in multiple Ministries. For example, CCHP collaborated with the Ministries of Education, Youth and Sports, and Public Health to orient 2,396 parents and 2,324 community leaders and train 1,766 teachers and 191 school district staff on how to train and support YPEs.
• Training: 2,100 YPEs trained on the Five Life Skills curriculum, split almost equally between young men and young women (53 percent and 47 percent, respectively). Of these YPEs, 1,592 were in-school YPEs and 508 out-of-school YPEs (76 and 24 percent, respectively).
• Youth engagement: 22,476 youth participated in YPE-led learning sessions across 248 schools and 127 community youth organizations.
• Model and Mentor Families: 176,180 youth households became Model Families, and 90,605 were recognized as Mentor Families. 
• Invitation cards distribution: CHVs distributed 426,561 FP invitation cards to regular users under the age of 25. 

• Youth contributions recognition: Communities lauded the achievements of Model and Mentor Families and YPEs during community-led gatherings, school events, and as part of national and international events, including World Youth Day, World Contraception Day, International Women’s Day and World Health Day. These efforts increased the visibility of youth as active participants and leaders in community health.

4. Recommendations and Lessons Learned.

The CCH project’s experience reinforces that CHWs play a crucial health promotion role, providing information and counseling, while increasing service utilization by youth. In addition, they are effective preventive service providers for short-term contraception methods for youth, thus filling gaps in the health system (11). Comprehensive approaches for reaching youth with health information and services are essential to improving young people’s health-related knowledge, attitudes, and skills and increasing their access to health services. CHWs can consider the following ideas when considering options to meet the needs of young people:

1) Engaging out-of-school youth. The Program found that investing in integrating income-generating activities for out-of-school youth or compensating YPE may increase their involvement and retention in this role (12).  Since out-of-school youth were less available and less willing to engage in unpaid voluntary YPE role because finding a source of income for themselves and their families took priority. Many youth who expressed initial interest in the YPE program expected to be compensated by the Program. After learning this was not the case, about half the youth expressed that they needed to pursue income-generating activities instead. The Program worked closely with community youth organizations and village heads to find non-financial means (e.g., t-shirts and hats) to motivate YPEs. However, these means do not address the core financial needs of potential YPEs, particularly those who are no longer in school.

2) Engaging in-school youth in decision-making with education leaders.  Advocacy actions will mobilize decision makers to expand and empower youth as advocates for their peers in schools. Through close collaboration with the Regional Directorates for National Education and local school districts, each school determined how YPE activities would fit into school schedules. In most cases, the program was after school.  Allocating sufficient time for YPEs to conduct the 10-hour sessions each semester within what was already a full class schedule required careful planning with teachers and school leaders.

3) Parents’ engagement in YPE activities. Programs and policies should address cultural and social factors that negatively influence parent communication about reproductive health (13). The Program’s efforts to involve parents in the YPE approach aimed to expand the promotion of improved health behaviors and allow parents to become important health leaders as they support youth.  Only a minority of parents declined to participate because of taboos surrounding sexual and reproductive health or because the educational divide between parents and children limited their participation. Future programs can increase parents’ willingness to engage in youth activities by addressing taboos surrounding sexual and reproductive health, which will also expand parents’ role as a respected and supported source of sexual and FP information.

5. Key takeaways from CCHP’s experience include the following:

Strengthen relationships between YPEs and CHVs. Having a trusting relationship between CHVs and YPEs helped ensure that YPEs feel comfortable referring to their peers in the first place. Enhancing CHVs’ ability to create an atmosphere of trust where sensitive issues can be discussed freely and without judgment is critical, especially for unmarried youth and the 10-14 age group.

CCHP’s Five Life Skills approach of training school district staff, teachers, and community youth leaders, and including parents in the process before moving on to the training program for youth, helped the Program obtain input and approval from the community. In particular, the Program involved parents to help them feel more at ease talking with their children about sexual and reproductive health issues and to ensure the continuity of the lessons their children learned through Program-led youth activities. 

Though it remained a challenge, the Program identified some effective actions for scheduling YPE activities with schools. For instance, CCHP encouraged schools to allow in-school YPE activities to start at the beginning of the school year, allowing enough time to complete the learning cycle of 10 sessions each semester. Developing a consistent and regular schedule encouraged attendance and participation in YPE learning sessions. The program also determined that the quality of YPE learning sessions was best when the sessions were held once per week (compared to multiple times per week) and that the interval between sessions should not exceed one week.

The highly interactive techniques used throughout the YPE Five Life Skills curriculum allowed youth to participate in an activity, reflect on their own experience, discuss what they learned, and then apply their learnings. This method provided youth with accurate information while developing their self-confidence, giving them a chance to practice new skills, and directing them to health information and services in their community.

Creating space inside or outside of school settings for youth to ask questions, discuss and share what they learned through Five Life Skills sessions and other cross-cutting youth activities helped to reinforce improved health behaviors. As part of the Five Life Skills approach, some facilitators and in-school YPEs formed clubs for YPE students based on their talents and interests, including a singing club, theater club, and language club.

6. References

1. Guttmacher Institute. “Adding It Up: Investing in Contraception and Maternal and Newborn Health,” December 2017.
2. World Health Organization. “Family Planning and Contraceptive Methods,” June 2020.
3. Guttmacher Institute. “Adding It Up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents in Sub-Saharan Africa,” November 2018.
4. World Bank. “Adolescent fertility rate (births per 1,000 women ages 15-19)” 2018.
5. Law on Marriage and Matrimonial Regimes (LMMR) 2007.
6. UNICEF. “The State of the World’s Children: Children in a Digital World,” December 2017. 
7. INSTAT and UNICEF. “Multiple Cluster Indicator Survey, (MICS) 2018”
8. Plan Stratégique National en Santé de la Reproduction des Adolescents et des Jeunes 2018 – 2020
9. https://www.jsi.com/resource/family-planning-and-youth-increasing-youth-access-to-family-planning-services-using-the-peer-mentoring-approach-in-the-mahefa-program-areas/
10. https://www.jsi.com/resource/madagascar-technical-brief-model-and-mentor-families-agents-of-change-for-maternal-newborn-and-child-health/
11. Glenton et al. Community Health Workers at the down of a new era :5 roles and tasks. Health Res Policy Sys 2021, 19(Suppl 3):128. https://doi.org/10.1186/s12961-021-00748-4. 2021
12. Simbarashe Mabaya et al. Retention and performance of peer educators and sustainability of HIV prevention services for adolescents in the Zimbabwe Smart-LyncAges project: an ecological study. Pan African Medical Journal. 2022;41:131. [doi: 10.11604/pamj.2022.41.131.29539]. 2022
13. Dessalegn W Tesson and al. Parent-young people communication about sexual and reproductive health in E/Wollega zone, West Ethiopia: Implications for interventions. Reprod Health. 2012; 9: 13. doi: 10.1186/1742-4755-9-13