No abstract

Access to youth friendly health services is vital for ensuring sexual and reproductive health (SRH) and well-being of adolescents. This study is a descriptive review of the effectiveness of initiatives to improve adolescent access to and utilization of sexual and reproductive health services (SRHS) in low- and middle-income countries. We examined four SRHS intervention types: (1) facility based, (2) out-of-facility based, (3) interventions to reach marginalized or vulnerable populations, (4) interventions to generate demand and/or community acceptance. Outcomes assessed across the four questions included uptake of SRHS or sexual and reproductive health commodities and sexual and reproductive health biologic outcomes. There is limited evidence to support the effectiveness of initiatives that simply provide adolescent friendliness training for health workers. Data are most ample (10 initiatives demonstrating weak but positive effects and one randomized controlled trial demonstrating strong positive results on some outcome measures) for approaches that use a combination of health worker training, adolescent-friendly facility improvements, and broad information dissemination via the community, schools, and mass media. We found a paucity of evidence on out-of-facility-based strategies, except for those delivered through mixed-use youth centers that demonstrated that SRHS in these centers are neither well used nor effective at improving SRH outcomes. There was an absence of studies or evaluations examining outcomes among vulnerable or marginalized adolescents. Findings from 17 of 21 initiatives assessing demand-generation activities demonstrated at least some association with adolescent SRHS use. Of 15 studies on parental and other community gatekeepers' approval of SRHS for adolescents, which assessed SRHS/commodity uptake and/or biologic outcomes, 11 showed positive results. Packages of interventions that train health workers, improve facility adolescent friendliness, and endeavor to generate demand through multiple channels are ready for large-scale implementation. However, further evaluation of these initiatives is needed to clarify mechanisms and impact, especially of specific program components. Quality research is needed to determine effective means to deliver services outside the facilities, to reach marginalized or vulnerable adolescents, and to determine effective approaches to increase community acceptance of adolescent SRHS.

Stunting is common in young children in developing countries, and is associated with increased morbidity, developmental delays, and mortality. Its complex pathogenesis likely involves poor intrauterine and postnatal nutrition, exposure to microbes, and the metabolic consequences of repeated infections. Acquired enteropathy affecting both gut structure and function likely plays a significant role in this outcome, especially in the first few months of life, and serve as a precursor to later interactions of infection and malnutrition. However, the lack of validated clinical diagnostic criteria has limited the ability to study its role, identify causative factors, and determine cost-effective interventions. This review addresses these issues through a historical approach, and provides recommendations to define and validate a working clinical diagnosis and to guide critical research in this area to effectively proceed. Prevention of early gut functional changes and inflammation may preclude or mitigate the later adverse vicious cycle of malnutrition and infection.

Changes in small bowel function early in infancy in developing countries are increasingly being demonstrated, probably accompanied by altered mucosal architecture in most individuals, including reduced enterocyte mass and evidence of immune activation and inflammation in the mucosa. These alterations appear to be the result of factors of uncertain nature in the environment, and may be a cause of growth faltering and stunting in young children. For these reasons, this constellation of findings is being referred to as environmental enteropathy, or as we propose herein, environmental enteric dysfunction. If the causes were known and effective interventions were available, strategies and policies to intervene at—or possibly before—birth could be developed and promoted in order to prevent subsequent malnutrition and recurrent infection, which are known to interact in a cyclical and synergistic manner in a downward clinical course often ending in death. Resources would be mobilized and applied differently, and the emphasis would change from treatment to prevention. In order to move in this highly desired direction, investments in research will be required to establish the criteria to assess environmental enteric dysfunction, determine its predictive value for growth faltering and stunting, identify the causes, and propose and test potential interventions. The concepts and tools are available. What is required is the decision to move forward along this pathway to better health for infants and children in low-income countries.