Approximately 6.6 million adolescents worldwide are currently displaced by armed conflict, many of them exposed to violence and acute poverty and separated from their families and communities(1). Like all young people, refugee adolescents have special needs during their years of development. Moreover, young people affected by conflict face additional barriers as they often lack sufficient education, health care, protection, livelihood opportunities, recreational activities, friendship and family support.
Refugee adolescents face additional difficulties that put their reproductive health (RH) at risk. Weakening of traditional socio-cultural constraints makes them more vulnerable to sexual abuse and exploitation. They may be forced to trade sex to pay school fees or feed younger siblings. Young refugees may begin sexual relations at an earlier age and are more likely to take the risk of engaging in sex without using a condom. Their RH is affected by: limited access to information, unsafe sexual practices, unwanted pregnancies, unsafe abortions and increased exposure to sexually transmitted infections (STIs), including HIV/AIDS. In situations of conflict, the dearth of youth-friendly services and trained providers are also significant barriers to ensuring young people's right to a healthy and productive life.
Recognising this dire situation, the Women's Commission for Refugee Women and Children (Women's Commission) supported a proposal to establish a fund to help meet the RH needs of adolescents affected by armed conflict. The Eleanor Bellows Pillsbury Fund for Reproductive Health Care and Rights for Adolescent Refugees (EBP Fund) was established in June 2000 to provide small grants to local and international organisations for specific adolescent RH projects.
The EBP Fund at work
During the first three years, EBP Fund-supported projects reached conflict-affected adolescents in Asia, Africa, Eastern Europe, Latin America and the Middle East(2). Projects ranged from supporting research and documentation of adolescent RH needs in Somalia and gender-based violence peer educator training in Kosovo to funding family planning services and trainings for adolescents in Colombia and culturally appropriate RH workshops for mothers and daughters in the Occupied Palestinian Territories. In addition, an intensive training programme was undertaken in Nepal to prevent STI/HIV/AIDS among teenage Bhutanese refugee girls.
In Northern Uganda the youth-led Gulu Youth for Action (GYFA) is working - despite the lack of security in the region - to raise awareness and communication about RH issues. Other local and international organisations provide back-up but it is youth leaders who set the agenda and ensure activities are youth-friendly. GYFA's leaders are facing up to a dilemma common to many organisations reaching out to youth - getting as many girls participating as boys. In 2003, a consortium of 13 local NGOs working on behalf of adolescent Burmese forced migrants on the Thai-Burma border formed the Adolescent Reproductive Health Networking Group (ARHNG. The objective of ARHNG is to develop the institutional capacity and management skills of member organisations for implementing adolescent RH projects. Members share information and experience, follow-up training activities and help each other access external resources. The Women's Commission began partnering with this network in 2003 by providing a small grant to Doctors of the World (DOW) Thailand which serves as the focal point for the network. Through their local office in Thailand, DOW provides the network's member organisations with the expertise of an international leader in health development and the accessibility of a field-based agency. DOW helps ARHNG to assess members' needs, plan strategically, apply for project funding and organise training. The use of networks and the designation of a lead agency for the network make it easier to incorporate a broader perspective of adolescent RH for an entire region.
Measuring impact
While it is possible to quantify specific outputs from adolescent RH projects, it becomes increasingly difficult to measure the ultimate aims of such projects - improved adolescent sexual and RH behaviour and, ultimately, improved RH and well-being. Using EBP Funds more than 61,000 adolescents have attended events offering RH training and education on issues such as condom use, prevention and treatment of STIs, family planning techniques and protection against gender-based violence. Messages have been conveyed via seminars, workshops, drama, discussion groups and video. At least 580 adolescents have been trained as RH peer educators and more than 2,000 have participated in peer-to-peer counselling sessions. Peer educator training not only offers adolescents important information but can also serve to build self-confidence and give youth the skills to advocate for their RH rights.
The EBP Fund also supported the distribution of brochures, fliers and pamphlets with RH messages that can be used alone or as teaching aids for educators and service providers. These materials have spread information about practising safer sex, using family planning methods and avoiding exposure to STIs. At least 10,000 condoms have been distributed free of charge, giving young people a chance to protect themselves from HIV and unplanned pregnancies.
Approximately 2,250 adolescent girls have received locally-made sanitary wear materials through EBP projects. In many refugee settings the lack of sanitary wear materials keeps refugee girls from attending school. They are also often forced to quit school by their parents who fear their daughters are more vulnerable to sexual assault walking to and from school. The provision of sanitary wear allows refugee girls to live with dignity and continue their formal education.
Many young people in conflict settings lack educational and work opportunities and have lost their social support system, increasing their risk of exploitation and abuse. Young people want and need education and livelihood training to become self-sufficient and to build their futures. Many EBP-supported projects have responded to the need for education and income-generating skills training by integrating these opportunities with RH training. More than 300 adolescents have received educational support and income-generation skills training through the adolescent-focused projects. For example, Shuhada Organisation in Afghanistan(3) used RH educational materials to increase the literacy skills of 20 young women and girls in their community. In Kenema in Sierra Leone, the Forum for African Women Educationalists(4) sponsored 55 girls to attend school, train as RH peer educators, receive safe motherhood support, learn about gender-based violence and receive free medical services. Team of Volunteers Against AIDS in the Democratic Republic of Congo sponsored income-generation workshops for 40 adolescent girls to gain skills such as dressmaking and shoemaking, while also learning about responsible sexual practices.
Community support for adolescents
Even when RH and education services are available, communities may not want adolescents to access them. Adults may fear that information will promote youth promiscuity. Service providers may not be trained to respond to the unique concerns of adolescents or facilities may not be young-people friendly. It is essential to educate parents and the community about young people's rights to health care. EBP-funded projects trained at least 175 parents at workshops on the basics of adolescent development, reproductive rights and parental obligations to support these rights.
Lessons identified
After three years the Women's Commission reviewed EBP-supported RH projects to cull lessons to inform future capacity-building projects.
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Effective RH projects for conflict-affected adolescents do not adhere to a set formula or model but are varied in their approach, creatively designed to be culturally appropriate and to meet the specific, pressing needs of adolescents in a particular community. A review of projects reveals many variations in methodological approach from peer education and cultural performances to awareness-raising workshops and establishing youth-friendly centres. Projects also vary their focus by RH technical area: safe motherhood, including emergency obstetric care; family planning and emergency contraception; sexually transmitted infections including HIV/AIDS; and gender-based violence. Adolescent RH project data show that effective projects are designed to meet the specific, pressing needs of the adolescents in each community and respond to the local context.
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Conflict-affected communities, especially adolescents themselves, are highly motivated to improve adolescents' RH but need capacity building, through technical guidance and support, to maximise the effectiveness of their projects. For instance, many EBP grant recipients had difficulty in identifying specific or measurable indicators which are key to evaluating project activities and ensuring that interventions are useful. Many organisations also need assistance in designing and evaluating their training and education programmes. Organisations, especially local ones, expressed the desire to learn about best practices from other RH projects and would benefit from the creation of a network involving those organisations supporting adolescent RH on a regional or global level.
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Adolescent RH projects must identify and involve refugee young people in the design, implementation and evaluation of all project activities to ensure they are full participants in programmes that affect their lives - a key recommendation of the 1994 International Conference on Population and Development. It is not enough to involve young people as peer educators - they should be included in all aspects of project design, implementation and evaluation.
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Peer-to-peer education strategies provide opportunities for meaningful adolescent participation, which, with quality training and careful project monitoring and evaluation, can maximise project impact while minimising financial costs. Although the adolescent experience varies widely by culture and individual, most adolescents are highly susceptible to peer influence. Young people represent an untapped community resource; providing opportunities for youth to participate in the creation and implementation of solutions to their own problems empowers them to become agents of change in their communities. The use of peer educators can also be a cost-efficient method of widely disseminating information. It is critical that peer educators receive sufficient and continued quality training. Careful monitoring and evaluation help ensure that training provides accurate information, via adolescent-appropriate methods that mitigate participant attrition. It is also essential to ensure that activities are supported by, rather than dictated by, adults. Peer educators need continuing support - from peers, parents or others in the community - to overcome obstacles they may face.
- Networks can help close gaps in service provision and strengthen limited capacities by facilitating coordination and collaboration among numerous and diverse adolescent RH projects within a particular region. Lack of coordination and collaboration may cause gaps or duplication in service provision. Several projects may focus on one technical area, while other technical areas are overlooked. Lack of collaboration can also cause projects to 'reinvent the wheel'. This lack of inter-organisational collaboration prevents the sharing of resources and good practices, leaving each organisation to repeat similar mistakes and miss out on benefiting from already tested effective interventions.
Next steps
The approach of supporting adolescent RH projects has enabled many adolescents and their communities to increase their awareness of RH risks and of employing effective methods of protecting and improving their RH. Awareness alone, however, does not necessarily produce behavioural change. Neither does it definitively cause a clear and measurable improvement in young people's RH status, which is the overarching goal.
After three years of activity, the Women's Commission is examining new strategies for increasing efficiency and coordination in supporting the RH of conflict-affected adolescents. One possibility is an increased focus on supporting international NGOs through the network model described earlier. Another alternative is targeting specific regions, such as sub-Saharan Africa or southeast Asia, and providing more sustained funding to organisations. Although new grant making is on hold during this strategic planning process, the Women's Commission continues to support adolescents around the world through its 14 current EBP-funded projects.
As the EBP Fund is currently the only ongoing fund to focus solely on the RH of displaced and conflict-affected adolescents, the Women's Commission has a unique opportunity to highlight the importance of advancing RH services among this neglected population. It is essential to build organisational capacity, share experiences about supporting good adolescent RH practices, identify resources that can be adopted to local contexts and advocate for more attention and funding for adolescent RH projects.
Most importantly, it is essential to continue to improve the lives of conflict-affected adolescents and to involve young people in this process. Adolescents are creative, energetic and important agents for constructive change within their communities - and they are the future.
Julia Matthews is the RH Project Manager and Sheri Ritsema the RH Project Specialist at the Women's Commission for Refugee Women and Children (www.womenscommission.org). Email: juliam@womenscommission.org and sherir@womens.commission.org
Notes:
- The exact number of displaced adolescents is not known. UNHCR estimates that there are 40 million displaced persons worldwide and that 50% of these are young people. The Women's Commission estimates that approximately one-third (i.e. 6.6 million) of these displaced young people are adolescents (ages 10-19). Variances exist between cultures, organisations and individuals in how they define the terms adolescent, youth and young people. WHO definitions are: 'adolescent' refers to ages 10-19; 'youth' to ages 15-24; and 'young people' to ages 10-24. The terms adolescents, youth and young people are used interchangeably throughout this article.
- For further information, visit www.womenscommission.org/pdf/ebp_.pdf
- See www.shuhada.org.
- See www.fawe.org.