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In this Viewpoint, Judith Bruce answers questions from Journal of Virus Eradication Editor, Sabine Kinloch-de Loës, on the importance of fulfilling the basic human rights of adolescent girls and their relationship with viral epidemics such as HIV. Judith Bruce is a graduate of Harvard University and a Senior Associate and Policy Analyst at the Population Council, New York, USA, whose work is aimed at building the health, social and cognitive assets of girls in the poorest communities in the developing world.

HIV and AIDS prevention efforts have relied heavily on providing information, and have sometimes provided a weak link to services, without perceiving or addressing the factors which make adolescent girls particularly vulnerable. Social factors, such as friendship networks, and economic factors, such as financial literacy and financial goals, independently but synergistically decrease girls’ risk of coerced sex or exchanges of sex for money, and increase their ability to cope in HIV-affected households. Current work focusing on HIV and youth is failing to reach many of the most vulnerable girls. This article discusses innovative interventions in four African countries, which explicitly address the distinctive social, economic, and cultural factors that shape girls’ vulnerability, and build up their health, social, and economic assets.

For too many girls worldwide, an emergency begins as an "event" and transforms into a lifetime. The adolescent girl is already at a triple disadvantage pre-emergency: her age, her sex, and her economic status all put her at risk. Her thin (or absent) friendship network, fragile access to safe public space, and tenuous claim on schooling are further strained or erased by displacement. Girls are maltreated and exploited, even before childbearing age; puberty dramatically elevates their risk for sexual violence, pregnancy, and HIV infection. Many bear or inherit children while still children themselves. Social norms travel with the girl, generating a paradox: Girls are controlled under the guise of protection while their rights are violated and their goodwill and capacities are drawn on to mitigate scarcities and family trauma. In the severest moments of an emergency, adolescent girls function as a default safety net or virtual credit card. A girl's assets--labor, time, integrity, and safety--can be deployed to underwrite the risks and to "smooth" others' material needs. She is the last to access survival resources, but the first expected to provide; she actively seeks out food, fuel, and water for her family. She may be encouraged or driven by circumstances to trade sex for goods or money; she may be forced into child marriages or short-term sexual liaisons for which her family (and intermediaries) receives money. Her lack of education undermines her own ability to obtain accurate information, discern dangers, or define realistic choices. Without a place to meet other girls and develop her voice and agency, she may doubt her abilities or blame herself for her circumstances. Sexual access to girls, promoted or simply not prevented, is not only a human rights abuse but an injustice that extends her crisis, whether through life-crippling pregnancies or disease (HIV, other sexually transmitted infections, and now, Ebola). he Girls in Emergencies (GIE) Collaborative--a group representing several major emergency response organizations--focuses on the adolescent girl because evidence reveals that she not only faces a multiplicity of risks during a crisis, but also because she remains invisible, unprotected, and unengaged, particularly in the crucial first 45 days of a crisis. Current practice lags behind field realities. To the extent that we identified "good practices," these are small in scale and implemented too late.... Language: en

In recent history, the number and scale of natural disasters, one of the major causes of humanitarian emergencies, have increased markedly. From 2000 to 2009, compared with the period from 1980 to 1989, there were 3 times more natural disasters across the globe, with climate-related events accounting for nearly 80% of the increase. Since 2008, natural disasters such as floods, storms, and earthquakes have displaced an average of 26.4 million people per year. Even after adjusting for growth in population, the likelihood of being displaced by a disaster today is 60% higher than it was 40 years ago. In 2013 alone, 97 million people were affected by natural disasters. Man-made disasters, the other major cause of humanitarian emergencies (by means, for example, of violence and conflict), remain a leading driver of displacement as well. According to the UN High Commissioner of Refugees (UNHCR), mass displacement reached unprecedented levels in 2014: "59.5 million individuals were forcibly displaced worldwide as a result of persecution, conflict, generalized violence, or human rights violations." Particularly in fragile and conflict-affected states, a complex mix of overlapping hazards--both armed conflict and natural disasters--plays a role in creating humanitarian crises, one that climate change is expected only to exacerbate. The University College London-Lancet Commission, in its landmark 2009 report, said, "Climate change is the biggest global health threat of the 21st century. Effects of climate change on health will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk." Among the billions of people at increased risk are adolescents (10- to 19-year-olds), who account for 1 in 5 people in the world, or about 1.2 billion. The vast majority--90%--of adolescents live in developing countries (including China), and approximately 510 million of this group are girls. The poorest adolescent girls living in the poorest communities--roughly more than 200 million girls living in households in the bottom 2 wealth quintiles--are at special risk for being deleteriously affected by climate change. Nonetheless, adolescent girls are not currently a specifically targeted, high-risk group in humanitarian relief efforts during emergencies, nor are they specifically engaged as a population whose involvement could advance national adaptation plans to mitigate the effects of climate change. In 2011, Plan Internationali published a valuable monograph entitled "Weathering the Storm: Adolescent Girls and Climate Change," that called attention to the particular vulnerability of adolescent girls to the effects of climate change. It was a prescient analysis. In the intervening 4 years, the effect of climate change has become more pronounced, and there is a clearer vision of its consequences. The human rights community has more urgently addressed the effect of climate change, especially on socially excluded groups, and practitioners have begun to organize an increasingly accelerated response to the plight of adolescent girls in humanitarian emergencies, both those caused by natural disasters and armed conflicts. The overall reaction to the cataclysm suffered by adolescent girls, however, has been slower than the data warrant. Language: en

In most developing countries, the majority of sexually active female adolescents are married. Although married adolescents are often assumed to be at low risk for HIV infection, little is known about the actual HIV risks these adolescents face or about ways to minimize these risks.Demographic and Health Survey data from 29 countries in Africa and Latin America were used to examine the frequency of factors that may increase HIV risk in married women aged 15-19.Several behavioral and social factors may increase the vulnerability of married female adolescents to HIV infection. First, these young women engage in frequent unprotected sex: In most countries, more than 80% of adolescents who had had unprotected sex during the previous week were married. Second, women who marry young tend to have much older husbands (mean age difference, 5-14 years) and, in polygamous societies, are frequently junior wives, factors that may increase the probability that their husbands are infected and weaken their bargaining power within the marriage. Third, married adolescents have relatively little access to educational and media sources of information about HIV. Finally, the most common AIDS prevention strategies (abstinence, condom use) are not realistic options for many married adolescents.New policies and interventions, tailored to the sexual and behavioral profiles of women in each country, are needed to address the vulnerabilities of adolescent wives. In some countries, delaying age at marriage may be an important strategy; in others, making intercourse within marriage safer may be more valuable.

In the past decade policy attention has turned toward adolescent reproductive health and social development issues. During that same decade women came to comprise half of those infected with HIV/AIDS. In some parts of the world most notably sub-Saharan Africa HIV prevalence rates among young women aged 15–24 outpace those of men in that age group by two to eight times. Of substantial consequence yet largely ignored is the fact that the majority of sexually active girls aged 15–19 in developing countries are married and these married adolescent girls tend to have higher rates of HIV infection than their sexually active unmarried peers. Thus married adolescent girls not only represent a sizeable fraction of adolescents at risk but they also experience some of the highest rates of HIV prevalence of any group. Nonetheless married adolescents have been marginal in adolescent HIV/AIDS policies and programmes and have not been the central subjects for programmes aimed at adult married women. It is time—indeed past time—to give substantially greater attention to the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks including HIV. Protecting these young women may not only serve to help prevent the disease from spreading from “high-risk” groups to the general population in their own generation but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group. (excerpt)

In the past decade policy attention has turned toward adolescent reproductive health and social development issues have begun to take centre stage in international development policy. During that same decade the shape of the HIV epidemic shifted with women of all ages now comprising half of those infected with HIV/AIDS. Much of that acceleration in the spread of HIV among women has taken place among adolescents. In some parts of the world most notably sub-Saharan Africa HIV prevalence rates among young women aged 15-24 outpace those of men in that age group by two to eight times. Of substantial consequence yet largely ignored is the fact that the majority of sexually active girls aged 15-19 in developing countries are married and these married adolescent girls tend to have higher rates of HIV infection than their sexually active unmarried peers. Thus married adolescent girls not only represent a sizeable fraction of adolescents at risk but they also experience some of the highest rates of HIV prevalence of any group. Nonetheless married adolescents have been marginal in adolescent HIV/AIDS policies and programmes and have not been the central subjects for programmes aimed at adult married women. We suggest that it is time-indeed past time-to give substantially greater attention to the process of marriage and specifically the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks including HIV. Our arguments and analyses suggest that married adolescents represent an acutely under-served group who in the context of an HIV epidemic are especially vulnerable. Epidemiological analyses have failed to appreciate the importance of HIV prevention to young married women who are unlikely to spread the disease through peer interactions. Yet protecting these young women not only serves to help prevent the disease from spreading from "high-risk" groups like sex workers and truck drivers to the general population in their own generation but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group. (excerpt)

This publication of the Population Council highlights examples of family planning and reproductive health programs that are providing unusually high quality care. Projects are selected for documentation by an advisory group made up of individuals who have a broad range of experiences within the field of reproductive health and are committed to improving the quality of services. This issue focuses on the history and achievements of the Manuela Ramos Movement in the field of reproductive health in Peru with highlights on the design and implementation of its ReproSalud project. The lessons learned and future challenges identified in the project implementation are discussed.

This report describes the experiences of the Family Planning Association of Kenya (FPAK) with use of Client-Oriented Provider Efficient (COPE) methods for assessing and improving quality of care in FP programs in Kenya. COPE actively involves providers in determining how care can be improved and developing practical solutions to a wide range of problems. This overview begins with a discussion of the history of FPAK and early attempts to improve quality of care followed by a description of COPE its initial use during 1987-90 and a new start in 1993. The COPE technique includes self-assessment client interviews client flow analysis (CFA) and a plan of action. The first use of COPE was a failure. The second time around the evaluation paid attention to staff needs for training information infrastructure supplies guidance back-up respect encouragement feedback and self-expression. The checklists were redefined to address client needs to be modular in form and to be used routinely and at low cost. The checklists were reframed as 10 guides of which 7 were devoted to clients rights and 3 to provider needs. CFAs were conducted only if serious bottlenecks occurred and were made more user friendly. COPE revealed major problems with supervision and poor skill levels and led to greater control at the clinic level. All staff are encouraged to attend and participate in problem-solving sessions. Use of COPE stimulated FPAK to seek client feedback on hours of operation method choice privacy safe services and continuity of supply. Six lessons learned are identified.

Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the "unmet need" for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led in turn to an emphasis on expanding family planning programs. This study analyzes survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge, fear of side effects, and social and familial disapproval. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.Since the 1960s, survey data have indicated that substantial proportions of women who have wanted to stop or delay childbearing have not practiced contraception. This discrepancy is referred to as the unmet need for contraception. The traditional interpretation, that these women lack access to contraceptive supplies and services, has led to an emphasis on expanding family planning programs. Recent estimates put the total number of women with an unmet need in the developing world at about 120 million. This study analyzes national Demographic and Health Survey data and related anthropological studies on the causes of unmet need and concludes that the conventional explanation is inadequate. Sub-Saharan Africa stands out as the region with the lowest potential demand and contraceptive prevalence and having the highest unmet need. The unmet need in Asian countries is only 14%. The proportion of women not currently seeking to become pregnant and those who do not want children rises from 29% to 73% between the lowest and the highest levels of development. The prevalence of contraceptive use also increases sharply between the lowest and highest development group: from 4% to 16% for spacing, from 3% to 43% for limiting, and from 7% to 59% for total use. Although for many environments geographic access to services remains a problem, the principal reasons for nonuse are lack of knowledge (25%), especially in Sub-Saharan countries, fear of side effects both life-threatening and non-life-threatening (20%), and social and familial/husband disapproval (9%), even when the women have never discussed family planning with their husbands or families. This finding underscores the need for expanded investment in services that not only provide contraceptives, but also attend to closely related health and social needs of prospective clients. Programs are likely to be most successful when they reach beyond the conventional boundaries of service provision to influence and alter the cultural and familial factors that limit voluntary contraceptive use.

Though male reproductive health has only recently begun receiving attention the experiences of two clinics specializing in that area suggest than men have significant interest in the services offered. Brazils PRO-PATER clinic devotes itself exclusively to the reproductive health concerns of men. Located in the city of Sao Paulo the clinic was initially created to get men interest in the idea of family planning. But concerns over the predominance of female sterilization in the country prompted the clinic to begin offering vasectomies in 1981 which has now become its main service. Those who receive the operation must first undergo a careful screening process. Refusing about 21.5% of those interviewed PRO-PATER has had only 17 requests for reversal from over 28000 operations in 9 years. In addition to vasectomies the clinic also offers treatment for sexual dysfunctions and infertility services. The clinic which opened a branch in another Sao Paulo district in 1988 also conducts research into family planning issues and provides training for physicians from Brazil and other Latin American countries. PRO-PATERs success encouraged the creation of a similar service in Colombia Profamilias Clinica para el Hombre. Established in 1985 the clinic sprung up from a womens family planning program. Initially plagued by problems of cultural resistance staffing and a low client load Profamilia now enjoys great success measured by its self-sufficiency its 5 branches and its increasing number of patients. Among the lessons learned from the successes of both clinics: a large demand exists for such services; mass media is invaluable in informing men about the availability of the services; good quality of service increases the legitimacy of such a controversial project.

This essay was written in response to a critical review made by Ross of one the authors previous publications. The authors agree with Ross about the unproductive nature of the debate over whether increased distribution is more important than service improvements in increasing contraceptive prevalence and about the fact that satisfactory access to modern contraceptives remains problematic in developing countries. In fact the authors made these points in the work which Ross critiqued. Ross was inaccurate when he said that the authors believe that access is not a problem. Instead the authors agree with Ross that access must include a range of contraceptive choices but they also note that access involves the additional factors of adequate counseling about side effects and opportunities to switch methods. Another issue remaining to be resolved is the role that access has in explaining unmet need. Women with unmet need can be broadly defined as those for whom access is the dominant issue and those for whom other obstacles are more important. As access improves women in the second group constitute a larger percentage of remaining unmet need. Thus for most women with an unmet need access is not more important than survey data indicate. Unmet need will remain a problem unless programs improve the quality of information given to clients and deal with social concerns underlying contraceptive nonuse.

The Population Council continues to resist setting quality of care standards for family planning programs. It contends that professionals responsible for each family planning program must define intended and achievable levels of care. The Population Council does claim however that a high quality program is client-oriented and assists clients in reaching their reproductive goals. Even though a high quality program would reduce fertility by increasing contraceptive use it must not execute fertility reduction policies that conflict with clients well being. 6 components of quality care include appropriate choice of methods responsible information technical competence interpersonal relations mechanisms to encourage continuity and appropriate mixture of services. A key problem with setting universal standard is that each country or program must validate the standards and make them work. For example standards may require providers to understand clients reproductive intentions and to help them choose a method which meets their needs yet the standards cannot define how they should do so. The standard setting process for individual countries and programs should include the technical and affective aspects of care and address the following: What quality of care does a program propose to offer can it offer is actually offered and is received by clients? Rapid assessment techniques can be used to compare the quality of care a program wants to offer and the care that is actually given to clients. Program managers can then discern gaps between intention and reality and reasons to improve service standards. In conclusion solutions to problems with quality of family planning care are only found locally.

Evaluation of birth planning programs has heretofore been done from the service provider or the policy-planner's point of view. It is time to begin evaluating family planning programs from the viewpoint of the user. This type of evaluation would involve measuring continuation rates over time and the degree of benefit over a reproductive lifetime. Evaluation should include individual and subgroup acceptance of various methods of birth control. Knowledge of the clients' needs can be assessed and applied at 3 points in the provision of family planning services: 1) during the planning stage of programs; 2) in response to modern programs, e.g., in response to perceived risks and benefits of certain offered methods; and 3) on a longterm basis, focusing on consequences of birth planning systems to individual health and well-being.

Womens organizations such as political professional social welfare religious community development family planning government program and commercial associations have increasingly assumed leadership in providing fertility control in the developing world as part of their concern with socioeconomic development and political change. The Nepal Womens Organization a political association initiated a program in 1973 to bring family planning services to 1000 villages assist in the official sterilization program and promote literacy and economic skill development. Volunteers selected from their villages on the basis of leadership and interest attend a 10-day seminar on family planning nutrition child care sanitation immunization literacy and marketing handicrafts. As a close relationship between acceptor and worker is essential each attempts to reach 20-30 women. The objective is to have 800 village workers operating by July 1978. The Womens Medical Society of Ecuador has provided clinic-based services for 8000 clients in urban slums since 1973. The Thai Nurses Association plans a new family planning service unit in addition to their research and publication efforts begun in 1975. Social welfare organizations in Korea Sri Lanka Pakistan Thailand Egypt and the Philippines are conducting family planning services. The Social Welfare Society of Pakistan and the Cairo Womens Club have active programs where volunteers are trained to serve their own communities. A womens leadership program conducted by the Korean National Council of Churches is reaching 1/3 of all women aged 20-44 serving 40000 users in the 1st year. Concerned Women a family planning association in Bangladesh enrolled 5634 acceptors and 154 underwent voluntary sterilization. A promising strategy by the Coptic Evangelical Services in middle Egypt has proved successful in 8 villages where the approval of the village leadership is 1st sought. The Raaidat program of Egypt has trained rural women as leaders to organize self-help programs. Population control and food production are the aim of 87 cooperative societies staffed by women of the Integrated Rural Development Program of Bangladesh.

A survey of abortion facilities in New York City revealed the existence of adequate resources for both early and late terminations of pregnancy. Several important weaknesses have been noted which can be related to the policies and practices of the performing institutions: less than adequate provision of postabortal contraceptive care, and counseling, primarily in private hospitals; wide variation in restrictive admission policies to minors; and substantially higher costs in private facilities. On the whole, private patients are more likely to be receiving less than adequate care than non-private patients with respect to counseling and contraception. This has implications for several long-term risks, namely: repeat and recurring abortion with the possibility of increased risk of premature delivery or spontaneous abortion, and other hazardous outcomes of pregnancy.

There are today some 200 women's health centers in the United States providing information and, in many cases, direct health and family planning services to women in a manner responsive to their needs and preferences, and that involves them in the design and provision of services. This approach to delivering services was specifically recommended by the International Conference of Family Planning in the 1980's held in Indonesia in April 1981. in addressing the challenges facing family planning programs in the decade ahead, the conference noted that in many parts of the world, women often have little control over decisions related to their own fertility. Furthermore, low levels of acceptance and use of family planning, which are characteristic of many programs, often reflect a failure to design and provide services in a manner that is responsive to the needs and perceptions of the users. The conference called for measures to improve the status of women, and recommended that women be involved in all aspects of program design, management, policymaking, and provision of services. In this special report, Judith Bruce describes how women-oriented services are designed and provided at one of the women's health centers, The New hampshire Feminist Health Center.