Toolkit to help to prepare for improving sexual and reproductive health service provision to adolescents at the district level.

FINAL DRAFT – December, 2006.

CONTENTS

INTRODUCTION………………………………………………………………………………Page 1

PART 1: USERS’ GUIDE..…………………………………………………………………Page 4

Overview………………………………………………………………………Page 4

Stage 1: Planning and preparation………………………………………..Page 4

Stage 2: Collecting information…………………………………………….Page 7

Stage 3: Documentation & analysis of information collected……………Page 11

Stage 4: Checking and presentation of findings………………………….Page 13

PART 2: INFORMATION COLLECTION TOOLS….……………………………………Page 15

Tool 1 – Framework for collecting & compiling existing information ……Page 15

Tool 2 – Interview guide for gatekeepers………………………………….Page 16

Tool 3 – Group discussion guide for adolescents…………………………Page 17

Tool 4 – Interview guide for health service providers…………………….Page 18

Tool 5 – Mapping existing services…………………………………………Page 19

ANNEXES:1 – Analysis framework……………..………………………………………..Page 22

2 – Example work plan….………………..………………………………….Page 23

3 – Sample briefing workshop agenda……………………………………..Page 25

4 – Possible sources of existing information………..……. ………………Page 26

5 – Additional information on methods of collecting information………..Page 27

6 – Session report format.…………………………………………………..Page 29

7 – Glossary of key terms…………………………………………………..Page 30

8 – Additional useful resources.…………………………………………….Page 31

1

INTRODUCTION

Background

Adolescents face a range of health problems, including those related to sexual and reproductive health (SRH), substance use, mental health, nutrition, violence and accidents. HIV and maternal mortality are two of the most important health problems for adolescents in developing countries: a large proportion of new HIV infections each year occur in adolescents, with a higher level of incidence in young women than young men; and pregnancy-related problems are a leading cause of death for adolescents, due mainly to complications from unsafe abortion and childbirth.

Access to quality health services, including sexual and reproductive health services such as STI management, antenatal care and contraception, is essential in addressing these problems. However, adolescents usually have very limited access to health services. Policy makers may not prioritise adolescents and therefore services may not be available. Where services are provided, adolescents may not know about them, or be embarrassed to seek them and have concerns about confidentiality. In addition, services may be inappropriate, costly, and unwelcoming to adolescents due to factors such as staff attitudes, long administrative processes, inappropriate opening hours or location.

To successfully address priority issues such as HIV and maternal mortality, adolescents’ access to services needs to be increased, by stimulating and meeting their demand for services. This requires provision of information and skills so that adolescents are aware of health services and products, and know when to seek them and how to use them; and provision of appropriate health services that attempt to overcome the barriers to access mentioned above – for example through creating a welcoming environment, and training staff to offer a range of appropriate services. All of this needs to be within a supportive environment, including appropriate policies as well as the support of local community leaders for the provision of SRH services to adolescents.

Successful SRH programmes are based on the local context and circumstances. Before trying to improve adolescents’ access to services, it is therefore important to first get a good understanding of what those circumstances are in your district. Since government health services alone cannot meet all adolescent health needs, it is also necessary to identify other existing and potential sources of advice, information and services, such as other government departments, private service providers and non-governmental organisations, so that networks and partnerships can be established with them.

Aim of this toolkit

This toolkit has been designed to help district-level health teams to collect information in order to get a better understanding of how local adolescent health services meet (or do not meet) adolescents’ needs, and what could be changed to increase their access. This information can then be used to inform district health planning and decision-making, specifically the development of local plans for improving adolescents’ access to quality sexual and reproductive health services. It is hoped that in this way, these district plans will follow national policy, and will also be relevant to the local reality.

The toolkit is intended for use by district health teams in conjunction with other local partners, prior to the development of local plans. In some cases an institution, such as an international NGO working in the district or a university department, will have been identified to provide mentoring support to the district health team. In these cases, this organisation will be able to provide support and guidance to the process.

The process will involve collecting information about adolescent health in the district in two phases: Firstly gathering and reviewing any existing information on this topic; and secondly collecting new information, through consulting key gatekeepers (such as political leaders, government officials, religious leaders and teachers), adolescents and health service providers to obtain their perspectives on these issues.

The aim is that by the end of the process, you will have information to answer the following questions:

  • Adolescent health needs & problems: What do adolescents and gatekeepers think are the main health needs and problems (including sexual and reproductive health) that adolescents in the district have?
  • Current service provision: What sexual and reproductive health services are currently provided in the district, either by the government or by other providers? This includes provision of information, services (such as STI diagnosis and treatment) and products (such as condoms and other contraceptives) to prevent, detect and treat health problems.
  • Use of health services by adolescents: Which health service providers do adolescents go to, and why? Which do they not use, and why not? (This includes providers of health services as well as health-related products.) How do adolescents and gatekeepers think that health service provision could be improved?
  • Other initiatives: Apart from health service providers, what other institutions or initiatives are promoting adolescent health and well being in the district (for example, providing SRH information and education or counselling services)?

After this information has been collected and analysed, it should be presented to key people at district level to form a starting point for local planning and decision-making. Annex 1 is a framework that will be used to help to compile, analyse and present all of the information collected.

The information gathered will therefore be used by the district health management team, in collaboration with other local actors, to inform planning and management of SRH services for adolescents in the district. This is the initial step in a longer planning process, and further, more detailed information will need to be collected later to help with developing appropriate interventions.

This toolkit is divided into two parts. Part 1 is a practical guide for users on how to carry out the process, and Part 2 is a collection of simple tools for gathering information. Additional useful information is included in the annexes. The user is advised to firstly read through the whole toolkit to get an overview of the process, and then re-read sections as necessary in order to plan and carry out the various activities.

Who do we mean by ‘adolescents’?

Adolescents are defined by WHO as all young people aged 10 to 19 years. However, they make up a very varied group, with a range of different needs and problems relating to sexual and reproductive health. For example, the problems and needs of boys will be different from those of girls; Adolescents of different ages will be at different stages of development and therefore have different needs; Even adolescents of the same age and sex may live in completely different circumstances – for example, they may or may not work, go to school, be sexually active, be married, or live in a poor family. All of these factors and many others will affect what needs and problems they experience throughout their adolescence.

Throughout this process it is important to bear in mind the wide range of people included in the term ‘adolescents’, particularly when you think about which adolescents to consult, and how to interpret and draw conclusions from the information you collect.

You should also use this process to think about which are the priority groups of adolescents in your district – those that have the greatest SRH needs, or the least access to SRH services.

For a list of simple definitions of other key terms that are important in this process, please see the glossary in Annex 7.

Part 1: USERS’ GUIDE

Overview of the process

The process is divided into four key stages, which are summarised in the following diagram and then described in detail below.

How long the process takes will vary from place to place, but in most cases it should take between 2 and 4 weeks.

Stage 1: Planning and preparation

Good planning is an essential part of this process, and following the steps outlined here will ensure that all necessary preparations are made before starting to collect the information.

Forming a team

The data should be collected by a team of at least 6 people, allowing the workload to be spread between them. Involving various people also brings in different useful skills and experiences. The team should include:

  • A team leader – probably a manager from the district health team, who is responsible for leading and coordinating the process.
  • Other members of the district health team and staff from local health facilities: for example, managers, community health staff, and nurses.
  • Other local key people: For example, staff from NGOs working with adolescents in the district; staff from other government departments such as education, youth, culture, sports, and social welfare; and members of community associations such as youth groups, village health committees and places of worship.
  • You could also include young people themselves – they are likely to be able to communicate more easily with adolescents than older adult team members are, and it will be useful to bring young people’s perspectives and ideas to the data collection and analysis process – for example, they may have good ideas about how to reach adolescents. Although not essential, there may be opportunities for involving young people if there is an NGO working with adolescents or young people in the area, which could assist in facilitating their participation in the process.

This team of at least 6 people should then be split into two groups of 3 for the collection of information. (If you have more than 6 people, you can split them into more groups of 2-3 people). You should aim to have at least one group of women and one of men, because it is better to have male team members collect sensitive information from male adolescents, and female team members from female adolescents.

Certain personal characteristics and qualities are important for collecting information from others. In selecting people to include in the team, if possible you should choose people who have some of the necessary skills and/or experience summarised in the following box.

Selecting sites

If possible, you should try to collect information in at least two different geographical areas, for example one in the urban centre and one more rural. This will mean that you can get an idea of the different issues faced by adolescents living in these two contexts. Both areas should be somewhere with a health unit where you intend to improve SRH service provision for adolescents in the future. You should be realistic – unless you are sure you will have the necessary resources (such as transport), do not choose a site that is difficult to access from the district centre. If you have very limited time and resources, just choose one area to work collect information in.

If you work in two sites, you can either collect the information in two phases (one site then the other), or simultaneously, with different groups working in different sites. This should be reflected in the work plan.

Planning what activities should be carried out, and over what time frame

It is essential to develop a work plan for the whole process, to ensure that all steps are covered and to allow any necessary resources to be identified.

Ideally the whole team should be involved in developing the work plan. This will mean that everyone has a clear common understanding of the process and what their role is. The plan should be completed before beginning the data collection, though it can be modified if necessary – in fact it is a good idea to include some flexibility, as unexpected changes can be necessary.

The work plan should consist of a list of all necessary activities, each with the desired output, person responsible, other people involved, and resources necessary (time, equipment, supplies, money). In Annex 2 you will find an example of a work plan.

Roles and responsibilities

For data collection activities the team should be divided into smaller groups of 2-3 people. One person takes the role of the facilitator, and leads the interview or discussion; the second person is the note-taker, responsible for documenting the discussion; and an optional third person is an observer who can support the facilitator and note-taker if necessary, and take care of logistical arrangements. One of these people should also be responsible overall for that piece of data collection. Team members can take turns in different roles.

Preparing and briefing the team

Once the team has been selected, all team members will need to be fully briefed about the information collection process before it starts. The best way to do this is to set aside a day at the beginning for the whole team to meet. During the day, the following topics should be explained and discussed:

  • Aims and overview of the process
  • The work plan (this should be developed during the meeting)
  • Roles and responsibilities of team members
  • Facilitation and interviewing skills
  • Agreeing definitions and local terminology for key terms (such as ‘sexual and reproductive health’, and ‘adolescents’).
  • Ethical issues
  • Pre-testing tools (optional)

Information on all of these topics can be found in this toolkit, which could be used as a resource during this briefing workshop. Annex 3 is a suggested agenda for the workshop.

Logistical preparations

Once the work plan has been developed, various logistical aspects should be prepared in advance of the data collection. These include:

  • Setting up meetings with leaders in the selected sites to introduce the assessment and obtain permission to proceed (if necessary)
  • Setting up meetings (interviews) with individuals and groups, including identifying venues for meetings
  • Providing adequate logistical support to the teams – in particular materials (pen, paper, folders, copies of toolkit), and transport if necessary.
  • After information has been collected, ensuring that documentation (notes and reports) are stored safely.

Ethical issues

While it is important to collect information from adolescents and gatekeepers to assess adolescent SRH needs, it is also essential to address any ethical issues that may arise, particularly through consulting adolescents who are under 18 years of age (and considered children). The guiding principle is that the best interests of the adolescent should be protected at all times, and that the assessment activities should do no harm to participants. All team members should be briefed on and understand the following specific guidelines:

  • Adolescents should only be consulted if necessary – in other words not if the information you need is already available from an existing source.
  • Participants should be provided with clear information about the assessment so that they can decide if they want to participate or not. They should also be informed that they can stop or withdraw from the discussion at any time. If adolescents are under 18 years old it may also be necessary in some settings to get consent from their parent or guardian for their participation.
  • You should always protect the identity of participants. This means treating information anonymously (for example, not recording the names of participants), and confidentially (not sharing the information given with other people, unless with the participant’s permission). These are ways of making sure that those involved don’t suffer as result of participating in the assessment or of information disclosed.
  • Think in advance about how you would deal with sensitive issues or needs raised, for example by referring adolescents to services where necessary, or providing them with information.

In addition, there are some general rules of good practice for working with communities, which should be followed:

  • You should always demonstrate that you respect and value the opinions of the people you consult
  • You should avoid raising expectations that won’t be met by being clear to those involved and the wider community about the aims of the assessment.
  • It is best to avoid providing incentives to participants. However, you should plan to meet them in a way that causes minimum disruption to their lives, for example at a time when they are not working and so won’t lose on income, at a convenient location that they do not have to travel to, and not at meal times.
  • At the end of the assessment you should provide feedback to those involved, by sharing your findings

Stage 2: Collecting information

There will be two main types of activity for collecting information: the collection of existing information, and consultation of community members and others to collect new information.

A. Existing information

It is important to first look at what information has already been collected, for example previous studies carried out on adolescent health in the area, or service use data from health facilities. Care should be taken however to only include information that is fairly up-to-date, and from a reliable source. See Annex 4 for examples of possible sources of existing information.