"Development practitioners point to participatory approaches as effective in increasing empowerment and accountability, two of the key factors in improving health services for the disadvantaged....However, to date, there have been no comprehensive evaluations conducted on the effectiveness of a community-based participatory process for adolescent reproductive health programs in developing countries, and, in particular, in reaching poor and otherwise disadvantaged youth."

In an effort to address that gap, this paper reports on a study that tested the ability of participatory approaches to improve reproductive health outcomes for the most disadvantaged youth in Nepal - where youth reproductive health needs are "acute", particularly for those who face constraints to accessing information and services due to not only socioeconomic status, but also gender, rural-urban status, and education status. Nepal's Ministry of Health (2002) reports that girls marry at an average age of 16, and 52% have begun childbearing by the age of 20. Among those giving birth, 55% of girls under age 20 reported receiving any prenatal care, 14% of the births were attended by trained personnel, and only 9% of deliveries were in a health facility. Less than 7% of married girls in the 15-19 age group reported using any method of contraception.

In this context, the authors examine data from the Nepal Adolescent Project (NAP), a 5-year (1998-2003) reproductive health project conducted by EngenderHealth, the International Center for Research on Women, and 2 local Nepali non-governmental organisations (NGOs) (New ERA Ltd. and BP Memorial Health Foundation). To test the effectiveness of participatory versus non-participatory approaches, evaluators implemented programmes in urban and rural study and control sites (4 sites total). In the study sites, there was a focus on involving the community and actively engaging disempowered groups (such as those living in poverty, young women, and ethnic minorities) through community-based groups set up during the project. The study site activities took into account broader development priorities voiced by diverse members of the community; for instance, peer education and counseling were linked with adult education programmes, activities to address social norms, and access to economic livelihood opportunities. In essence, the intervention package addressed structural, normative, and systemic barriers to youth reproductive health.

The evaluation finds that participatory approaches can effectively provide disadvantaged youth with the means to negotiate accurate information and services from parents, providers, and policy makers. For example:

• At baseline, both the study and control sites showed substantial differences between economically wealthy and poor young women's access to a health facility for pregnancy delivery. By the endline, poor young women in the study sites were closer in their access to prenatal care when compared to better-off women, but a similar change was not evident in the control sites.
• Before the intervention, an urban young woman in the study site was 16 times more likely to get prenatal care than her rural counterpart. By the end of the project she was only 1.2 times more likely to receive prenatal care. The control sites do not show a similar improvement.
• In all the sites at baseline, girls were less likely to be able to correctly identify at least two modes of HIV transmission when compared with boys. In the urban study site, the intervention led to a substantial improvement in knowledge among girls, such that the proportion of girls who were knowledgeable about HIV surpassed the proportion of boys. A similar change was not observable in the control sites.

Evaluators speculate that the participatory approach worked because:

• Young people were made active players in their own health; a key strategy here was tapping into and strengthening their existing social networks for information exchange and counseling.
• Youth and adult community members were empowered to demand accountability from providers and policymakers by building decision-making structures and coalitions.
• The study sites focused on altering not just reproductive health outcomes, but changing fundamental social norms and institutions among the disadvantaged.