National Adolescent Sexual and Reproductive Health Programme: Mid-Term Evaluation Report

EXECUTIVE SUMMARY Background and rationale Th e Ministry of Health and Population (MoHP) Nepal has endorsed the Nepal Health Sector Programme (NHSP) II (2010–2015), which aims to introduce 1,000 adolescent-friendly services (AFSs) in Nepal by 2015. Towards this, the Government of Nepal is implementing the National Adolescent Sexual and Reproductive Health (ASRH) Programme, which, by November 2012 had covered 516 health facilities in 36 districts. To assess the implementation of the National ASRH Programme, a mid-term evaluation was conducted by the Health Research and Social Development Forum (HERD) in collaboration with GIZ/GFA in selected health facilities in Doti and Banke. Th e mid-term evaluation is part of an operational research to determine the eff ectiveness of the National ASRH Programme and explored the understanding, perceptions and experiences of service providers and adolescents related to the implementation of the National ASRH Programme. Th e main aims of the mid-term evaluation were to: • understand the implementation processes and the wider context as it aff ects the National ASRH Programme in order to provide detailed explanations for the results of the fi nal evaluation; and • identify improvements that can be made to the intervention to increase access by adolescents to SRH services in the remaining period of the programme and ways of improving the likelihood of scaling up the intervention across Nepal. Data was collected for the evaluation in March 2013 in semi-structured interviews and focus groups discussions, mainly with health workers and adolescents, supplemented by peer ethnography interviews and observation by the researchers. As the study was conducted in selected health facilities in only two districts, the fi ndings may not be generalised to other GIZ-supported districts or to the many other intervention districts of the ASRH Programme that are supported by the Family Health Division or other donors. Th is report presents the fi ndings of this research. Implementation of the ASRH Programme Th e evaluation looked at the understanding of health workers about the National ASRH Programme and the extent of conforming with the programme guidelines. Th e National ARSH Health Programme was introduced in 2011 in 14 health facilities in Doti and 13 health facilities in Banke districts. Under the programme, health workers from selected facilities were provided with a two-day orientation about the programme; a display board with the AFS logo; information, education and communication (IEC) materials; and a small fl exible amount of fi nancial support for benches, curtains, and shelves to make the facility more adolescent friendly. Health workers in both of the study districts had attended orientations and understood that the programme is for young people (aged 10–19) undergoing changes associated with adolescence. Th ey said that the programme aims to create an environment that is conducive for adolescents to visit health facilities and receive services including by providing adolescent-friendly services and maintaining privacy. Th ey also understood that the programme is about providing counselling and services to adolescents related to SRH. Although most of the health workers understood that the programme is designed to address the specifi c needs of adolescents, some said that the programme is only about delivering family planning services and safe motherhood services. Although the School Health Programme and the training of peer educators do not form part of the ASRH Programme, health workers mentioned these activities as part of it. Th ey said that these activities have created awareness about ASRH services, which suggests that there should be more coordination between the ASRH Programme and programmes at the school level to create demand for ASRH services among adolescents. Key fi nding 1: All health workers are aware of the National ASRH Programme and its components, except for a few who said that the programme is only about delivering family planning and maternal health services. While the School Health Programme and the training of peer educators are not part of the National ASRH Programme, health workers stressed that these are effective ways to share about the ASRH services available at health facilities. Health workers were asked what activities have been undertaken to implement the ASRH Programme in their health facilities. In all facilities, health workers reported attending orientations, distributing IEC materials and making physical changes to the facilities, such as erecting curtains for privacy. Facilities had also organised orientations for the members of the health facility operation and management committee (HFOMC), female community health volunteers (FCHVs), students, teachers and members of the village development committee. Researchers observed that all of the health facilities had AFS boards displayed in visible places, except for Doti Hospital. Most HFOMCs did not have any adolescent members although some health workers remembered that adolescents had been members on previous committees. Some health workers mentioned schools, the community and peer educators as important in reaching out to adolescents and imparting SRH messages. Key fi nding 2: Health facilities have oriented selected FCHVs, teachers and other people in the village development committee about the National ASRH programme and health workers perceive community awareness to be a key factor in facilitating adolescents’ access to SRH services. Th e study also looked at how health workers are recording and reporting data on the ASRH Programme and what diffi culties they face in doing so. Health workers stated that they complete the monthly reporting form for the ASRH Programme by referring to diff erent registers and send the data along with the HMIS 32 form. Some health workers said that it is diffi cult for them to keep records because they have to look through several registers and suggested a separate recording format for the ASRH Programme. Irregular reporting appeared to be an issue, as was lack of follow-up or refresher training. In relation to monitoring, health workers reported that GIZ/GFA staff visited the facilities along with the focal person from the District (Public) Health Offi ce. Th e issue of limited resources was raised in the interviews – there is no budget to visit health facilities under the programme. An annual review at the district level was suggested by health workers to enable them to address the diffi culties and challenges in implementing the ASRH Programme. Key fi nding 3: The recording and reporting of the ASRH Programme has not been regular and consistent. Health workers mentioned not having a separate recording register for the programme and suggested that the programme be included in the HMIS 32 (monthly reporting format). Interaction between health workers and adolescent users Th e study examined adolescents’ access to health services and the behaviour of health workers in delivering AFSs. In relation to access to health services, health workers said that adolescents visit health facilities mostly for contraceptives, as well as for other SRH problems. Th ey also mentioned that a few adolescents presented with concerns about physical changes and their appearance. Health workers agreed that unmarried adolescents visit health facilities more than married adolescents and adolescent boys more than girls. However, the demand side of the programme is weak, with only a few adolescents reporting that they had visited a health facility for SRH services. Among the focus group discussion participants who had visited a health facility, most said that they visited the facility to take condoms; a few had gone with friends who had sought services for erection problems and rashes around the sexual organs. Other participants said they buy condoms from the nearby medical store instead of visiting the health facility. Most adolescent girls in Doti had not visited a health facility, but in Banke adolescent girls had been to a facility, either for themselves or accompanying their friends or sisters-in-law. Adolescent girls visited health facilities for menstrual problems, the oral contraceptive pill and condoms; some had friends who had been to a health facility for an abortion. Married adolescents reported visiting health facilities for antenatal checkups and vaccinations. Health workers said that sometimes adolescent girls come to ask about pimples or for a remedy for pain during sexual intercourse. In relation to the behaviour of health workers towards adolescents, all health workers interviewed emphasised that there have been signifi cant | X | | XI | changes in their behaviour since the introduction of the ASRH Programme. Th ey said that they used to think that giving young people access to contraceptives would ‘spoil’ or corrupt them and that adolescents should not be talking about SRH or using contraceptives. Now, some even stated that adolescents have the right to know about and use modern family planning methods. All health workers stressed that they do not ask the marital status of adolescents seeking family planning services. Th e study found an increased realisation of the importance of SRH among health workers and of the need to deal with SRH issues in privacy. Th ere is an evident awareness among health workers of how they need to respond to adolescents’ SRH needs. Some of the health workers mentioned that high patient fl ows mean that they cannot give as much time to adolescents as they should. Some health workers pointed to a knowledge gap regarding specifi c aspects of ASRH (e.g. emergency contraception, sexually transmitted infections) and suggested that a training would be helpful on technical aspects of the programme as well as refresher training on other aspects. Th ese comments and the concerns of the focal person at the central level indicate that health workers require better skills to deal with adolescents and further training could be of use to them. Adolescents were asked how health workers responded when they visited the health facility for SRH services. Adolescent boys had mixed experiences, but most gave positive feedback and said that the health workers counselled them well and answered their queries. Th ey also shared that they could take condoms easily from health facilities. Many participants shared that the health workers taught them how to use condoms properly and advised them not to have unprotected sex with multiple partners. Adolescents said that the health workers assured them that they would maintain confi dentiality and privacy. Th e fi ndings of peer ethnography also suggest that confi dentiality is maintained. While most adolescents were pleased with the health workers’ behaviour and said that they would happily go back to the health facility again, some did not have good experiences. Some adolescents shared that the health workers asked whether or not they were married when they went to take condoms. Some of the adolescent boys mentioned that the health workers asked the question in a teasing way or made ‘fun’ of them. Similarly, adolescent girls, with few exceptions, said that they found the behaviour of health workers good and that the health workers talk to them in a friendly manner. Th ese girls also shared that there are separate toilets for males and females. Th ey mentioned that the ‘sisters’ maintain privacy by taking them into a separate room. However, some adolescent girls in Doti were discouraged by health workers’ behaviour. In some cases, health workers were judgmental. Such behaviour from health workers creates a sense of mistrust among adolescents and discourages them from visiting health facilities and discussing problems with health workers. Key fi nding 4: All health workers stated that there have been signifi cant changes in their behaviour as a result of the programme. They shared their previous reluctance to provide contraceptives to adolescents as they thought it would ‘spoil’ them and their previous belief that adolescents should not talk about SRH or use contraceptives. Now, when asked about changes in their behaviour towards adolescents seeking SRH services, almost all health workers expressed adolescentfriendly attitudes. However, one health worker mentioned a gap in the training of health workers, which was also stressed by the focal person at the central level, namely, that, in addition to managerial aspects, such training should also cover more technical knowledge and skills on SRH topics and on the counselling of adolescents in SRH. Key fi nding 5: Health workers were aware of the importance of maintaining privacy and ensuring confi dentiality while providing services to adolescents. They mentioned using curtains or meeting adolescents in ANC clinics, but that high patient fl ow sometimes does not allow them to give much separate time to adolescents. Key fi nding 6: Few adolescents stated that they had visited health facilities for SRH services. Most of those who had visited related positive experiences, while a few had bad experiences regarding the attitude of health workers. According to health workers, unmarried adolescents visit health facilities to access services related to the ASRH Programme more than married adolescents. Furthermore, adolescent boys visited health facilities more than adolescent girls. At the same time, adolescent girls tended to have detailed knowledge about the specifi c health services offered, e.g., for STIs, menstrual problems, acne, pain during sexual intercourse and even abortions. Most adolescents who visited health facilities shared that they were happy with the health workers’ behaviour and that health workers treated them in a friendly and helpful way, did not ask for their marital status and maintained confi dentiality while providing information and services. Adolescents who said that they had never visited a health facility for SRH services were asked their reasons for not visiting. They said that they feared that their issues would be talked about and that they would feel embarrassed. These adolescents were often not aware that health facilities offer confi dential services in private. Boys in particular said that they feel uncomfortable because the health workers are senior to them. Adolescents also shared that in some cases the health workers are relatives, which adds to their discomfort as they feel shy and fear that the health worker might tell their parents. They also said that they fear running into neighbours or people they know at the health facility. Some adolescents said that they could not fi nd the time to visit a health facility because of the long distance to school and the need to do household chores. Instead they shared their problems with friends or their mother and, hence, did not feel the need to visit a health facility. Key fi nding 7: Those adolescents who had not used SRH services were concerned about confi dentiality, which seems to be one of the main reasons for adolescents not visiting health facilities for SRH services, in addition to feeling embarrassed to talk to health workers who are older than them or acquaintances. A set of eight adolescent-friendly IEC booklets on issues related to adolescents’ SRH and rights have been produced and distributed to all public health facilities that provide AFSs and to schools in the catchment area of these facilities as part of the National ASRH Programme. Both the health workers and adolescents who have read the booklets found these materials to be very helpful. Health workers have said that adolescents visit health facilities to read these booklets. Th e health workers maintain that the materials are adequate in quantity for adolescents to come and read, but not for wider distribution, except for in Baijapur where the health workers said that they have been distributing the booklets. Health workers also said that they had distributed the booklets to school libraries and community libraries. In addition to the booklets, health facilities that provide AFSs are provided with ASRH posters, an ASRH fl ipchart and comic book. Key fi nding 8: Most boys interviewed were aware of the IEC materials available in the health facilities, but only a few boys and girls said that they ha

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Peer reviewedPublisher PD

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