Adolescents in Bangladesh: A Situation Analysis of Programmatic Approaches to Sexual and Reproductive Health Education and Services

"[I]ssues surrounding sexual and reproductive health (SRH) remain a cultural taboo, especially for adolescents and young unmarried people. Adolescents in Bangladesh too often enter their reproductive years poorly informed about SRH issues, without adequate access to SRH-related information or services."

To inform the development of effective, inclusive, and sustainable programmes that can operate at scale, the Evidence Project/Population Council, with support from United States Agency for International Development (USAID)/Bangladesh, conducted a review and situation analysis of adolescent sexual and reproductive health (ASRH) programming in Bangladesh in the last decade. This report presents findings and recommendations from that study, including programmatic and evidence gaps, as well as best practices.

ASRH programmes address the specific SRH needs of 10- to 19-year-olds, as distinct from those of adults; some programmes also include youth up to age 24. ASRH programmes seek to raise awareness or increase knowledge of SRH among adolescents or improve services for adolescents related to such issues as sexual health, reproductive health, maternal health, sexually transmitted infection (STI) prevention and care, HIV/AIDS prevention and care, menstrual hygiene and management, and family planning. As noted here, the Government of Bangladesh (GOB) has articulated its commitment to improving access to ASRH services through numerous policy and programme documents, which provide the basis for engaging with the government, nongovernmental organisations (NGOs), and private sector partners; new networks and forums are being created to share knowledge, experience, and research, and to promote combined interventions (e.g., education and health services).

The Evidence Project/Population Council team's analysis of 32 ASRH programmes and interventions implemented between 2005 and 2015 identified the a few key trends in the thematic focus areas of reviewed projects. Namely, there is a lack of SRH programmes that are exclusively focused on adolescents. Adolescent-specific programming often includes SRH as a secondary component, strategically bundled with other interventions. ASRH programmes focus predominantly on girls, with little specific attention to boys. There is also a critical gap in SRH information and services for unmarried adolescents, especially girls. Sexuality, sexual identity, and recognition of diverse identities are missing in the landscape of ASRH programmes.

In terms of the programming approaches, the review found that traditional awareness raising approaches remain the most common and include community-based, school-based, and peer educator models. There are issues such as the lack of a strong base of evaluation and evidence for these models and implementation challenges, such as: "One limitation of community mobilization models is that adolescents and youth continue to be largely excluded from these community dialogue processes and are not engaged in community decision-making. For community mobilization to be truly successful, youth and adolescent voices must be heard and appreciated by these influential gatekeepers and leaders. There has been a recent shift from treating adolescents as passive and powerless to recognizing that they can be effective agents of change..."

Service delivery was the second major approach used in ASRH programming in Bangladesh, used by 19 of the 32 programmes. Of these, most included both clinical services and non-clinical services (SRH information and counseling, but no medical intervention). The GOB-instituted Adolescent Friendly Health Centers (AFHCs) are built as parts of existing facilities where community members (both women and men) already seek healthcare, which may reduce the stigma and other barriers adolescents - especially unmarried girls - face when seeking SRH information and services.

Using a case study approach, the report examines a handful of programmes have begun to implement what are defined here as new, innovative approaches to improving ASRH in Bangladesh. These include sports-based programming, incorporation of mental health counseling, and youth- and woman- friendly pharmacies, and use of information and communication technology (ICT). To elaborate a bit on the latter: BALIKA (Bangladeshi Association for Life Skills, Income, and Knowledge for Adolescents) used interactive applications on laptops and tablets, among other tools, for ASRH awareness building, skills building, and livelihood training. Generation Breakthrough engages a youth audience in a range of social- and health-related topics through a weekly radio show 'Dosh Unisher Mor', which takes adolescents' comments and questions via SMS (text messaging). SHRH-E, UBR, and Tarar Mela all use toll-free mobile phone services to provide ASRH information to adolescents through tele-counseling. Although these approaches hold promise, additional research is needed to strengthen the evidence base for their impact and effectiveness, according to the report.

Based on the 32 programmes examined, this review identified future actions to develop, refine and improve ARSH programming in Bangladesh:

• Employ multifaceted programmes, combining SRH with diverse interventions to enhance access to information and services. By combining sensitive ASRH issues with more acceptable themes (e.g., livelihoods, empowerment, maternal health, or the prevention of child marriage) and approaches (e.g., use of mass media), these programmes can circumvent cultural and societal barriers.
• Expand the number of interventions that specifically reach out to younger adolescents, unmarried girls, and underserved groups such as boys and urban adolescents. Efforts to deliver information, services, and support for these vulnerable groups could be strengthened through policy initiatives (e.g., prioritisation of underserved groups in the National Plan of Action for Adolescents), for example.
• Encourage age-appropriate intervention design through innovative and tested approaches, such as storytelling and art-centric and psychosocial approaches, to address underrepresented needs of adolescents.
• Strengthen monitoring, evaluation, and research designs to evaluate current interventions and create a culture of evidence-based programming and policymaking. For example, although global evidence does not indicate that peer-led models demonstrate significant impact to beneficiaries, this model is still frequently used in Bangladesh. "A culture of generating and using rigorous evidence for program design, refinement, and scale up must be fostered. Although two randomized control trial evaluations identified in the review - among the largest randomized controlled trial (RCT) evaluations of their kind in the world - are encouraging and indicate the capability in Bangladesh to conduct rigorous studies, their resource intensiveness make them difficult to implement. A stronger emphasis must be placed on cost-effective data collection, developing and applying strong but easy-to-use monitoring systems, and the use of analysis tools that deliver results that can be used to improve current programs."
• Support and provide continuity to the critical role of the GoB in leading the ASRH field. "The government can lead the way in providing sustained leadership in coordinating partners to avoid duplication of effort and fragmented programming. Similarly, implementing partners and stakeholders should seek collaborations with the government to implement clinical and non-clinical services targeted towards adolescents through the government's service delivery network as well as seek collaboration among each other to ensure the most efficient use of resources and comparative advantage of expertise."

Click here for the 62-page report in PDF format.
Click here for the accompanying 12-page policy brief, "Adolescents in Bangladesh: Programmatic Approaches to Sexual and Reproductive Health Education and Services".